Every finding on record at Elevate Care Country Club Hill

Based on interview and record review, the facility failed to supervise one resident that was identified as a high risk with severe cognitive impairment and a history of falls who required one person assist with transfers. This affected one of three residents (R1) reviewed for falls and supervision. This failure resulted in R1 having an unwitnessed fall while self-transferring sustaining left cervical spine (C1) and (C5) fracture.Findings Includes: R1 current diagnoses include but not limited to Alzheimer Disease, Parkinson's Disease, Dementia and a history of falling. R1Minimal data set section C (cognitive patterns) dated 4/22/26 documents a score of three which indicates severe cognitive impairment. Section GG (functional abilities) documents: R1 required supervision or touching assistance with walking ten feet (once standing, the ability to walk at least ten feet in a room, corridor, or similar space).R1 Fall scale evaluation dated 2/18/26 documents: R1 was at high risk for falling. Has the resident ever fallen before? Yes. What type of gait does the resident exhibit? Weak. Mental status (measure the resident self-assessment of his/her own ability to ambulate. Ask the resident, are you able to go to the bathroom alone, or do you need assistance? Does the residents' response to the above indicate they know the limits of their abilities to ambulate safely? Overestimates or forget limits.R1 Nursing note dated 5/30/2026 documents: Writer observed the resident on the floor in the bathroom face downR1 Fall report dated 5/30/26 documents: Nursing description: Writer heard a loud noise upon rounding. Writer observed the resident (R1) in his room, observed to be in the bathroom door frame on the floor in the bathroom face down. Resident description: Resident unable to give description. Was this incident witnessed. N (no). Upon assessment, resident sustained injuries to right forehead, right eye, right check and right elbow observed skin tear/laceration to right forehead. Resident observed moaning, when asked where is the pain, resident unable to state where the pain is located. Mental status: Oriented to person. Oriented to place. Predisposing Physiological Factor: confused, Gait Imbalance: Impaired memory, weakness.Facility serious incident report dated 5/30/26 documents: R1 who was alert and orient times one was involved in incident with a fall with physical harm or injury. R1 was observed in the bathroom on the floor. R1 had a laceration to the right forehead. Per staff, R1 stated he was attempting to go to the bathroom. R1 complained of pain unable to state where pain was located. Upon thorough investigation by the interdisciplinary team (IDT), prior to the incident, R1 was observed in bed sleeping, bed in the lowest position and call light within reach. R1 then independently took himself to the bathroom and lost his balance while R1 was noted barefoot at the time of the event. It has been determined that R1 got up from bed without assistance walked to the bathroom where he lost his balance and felt to the floor. R1 was sent to the hospital. Diagnosis C1 and C5 fracture. On 7/14/26 at 10:25am, R1 was observed sitting in a high back wheelchair. R1 was assessed to be alert to name only. V3 (R1's Power of Attorney/POA) was present. V3 said he was informed by staff that R1 had an unwitnessed fall, and staff did not know how long R1 had been on the floor. V3 said, R1 sustained a fracture to C1 and C5. On 7/14/26 at 1:40pm, V6 (Assistant Director of NURSNG/ADON) said, R1 was alert to his name only with a history of falls due to an unsteady gait and transfers. V6 said, V4 (nurse) reported hearing a sound, entering R1's room and saw R1 on the floor face down. R1 reported at the time of the incident, he was trying to use the bathroom. V6 said, R1 required one person assist with ambulation. V6 said R1 had fallen because he got up and went to the bathroom without staff assistance. On 7/14/26 at 2:32pm, V5 (Certified Nursing Assistant/ CNA) said, she was the aide that put R1 in bed. V5 said, she laid R1 down, gave him his call light and put the fall mat on the floor. V5 was unable to recall which side the fall mat was placed and went to compete her rounds. V5 said she checked on R1 between 8:30 and 9:30pm, then right before 10:00pm rounds she heard a boom. V5 said, R1 moves like lighten (fast). R1 is a busy body (constantly moving). V5 said, while R1 was on the floor he said he had to go to the bathroom. V5 said, we have a sitting program to monitor the high risk fall residents. V5 said, R1 is a busy body, getting up/down and constantly moving around. On 7/14/26 at 2:14pm, V7 (CNA) said, R1 likes to get up and walk. R1's room door was cracked half open on the night he fell. V7 said, R1 was observed on the floor blood coming from his head. V7 said, she saw the floor tile markings/imprint on R1's forehead. V7 said, the floor tile marking came from the impact of R1's fall. R1 fell hard. V7 said, normally R1 has a one-to-one (1:1) monitor. A 1:1 monitor is when a staff member sits with him to make sure he doesn't get up unassisted. On the night of the incident, the CNA assigned to be R1's sitter had her own set of residents that she had to provide care to therefore she was unable to sit and monitor R1. V7 said, R1 had a sitter because he was a high fall risk. V7 said, every night R1 attempts to get up from sitting in wheelchair or lying in the bed. V7 said, when R1 gets up, he will always say he has to use the bathroom even when he is clean and dry.Witness statement from V7 dated 6/3/26 documents: V7 was sitting at the nursing station when she heard a loud noise. V7 got up to round with the nurse on rounding in R1's room. V7 observed R1 on the floor in the bathroom door frame with his face on the floor. Resident (R1) kept trying to get up from the floor and V7 observed resident moaning and groaning,On 7/14/26 at 3:35pm, V4 (Nurse) said, she heard a boom (loud noise). V4 said, she entered R1's room. V4 said, R1 was face down on the floor with the upper half of his body (head) in the bathroom and the other half of his body (legs) outside the bathroom. V4 said, R1 was bleeding from his forehead. R1 reported he was trying to go to the bathroom. V4 said, the right side of R1's forehead and around his right eye was bruised. V4 said R1 required one person assistance due to his legs being weak. If a resident has a 1:1 sitter, that staff member must be within arm's reach of the resident even when that resident is in bed sleep. V4 said, the call light was not triggered when R1 fell. When asked if R1 could pull the call light V4 said, maybe or maybe not. Witness statement from V4 dated 6/3/26 documents: While sitting at the nursing station, V4 heard a loud noise. V4 got up from the nursing station to see what the noise was, V4 went into R1's room. V4 observed resident lying in the bathroom door frame supine, resident (R1) was observed moaning. Complaints of neck pain, resident unable to give number (of pain). On 7/14/26 at 3:47pm, V2 (Director of Nursing/DON) said, the 1:1 monitor schedule for the high risk fall residents is for the television room. High risk fall residents are monitored every two hours and as needed when they are in their bedroom or asleep.On 7/15/26 at 1:31pm, V6 (ADON) said, if a resident is high risk for falls that resident will have a staff member sit with them when they are in the dining room, activities or awake. When a high risk fall resident is in their room or sleep, they are monitored every hour by the nurse or certified nursing assistant.Witness statement from V8 (CNA) dated 6/3/26 documents: V8 saw the nurse and CNA running into a resident room. V8 immediately went down to R1's room and observed R1 on the floor in a supine position. Resident (R1) was still alert attempting to get up from the floor while being assessed by nurse on the unit stating he needed to go potty. V8 observed resident with a laceration to the right eye. V8 was unavailable for this survey.On 7/15/26 at 3:04pm, V9 (Nurse Practitioner) stated, R1 is very impulsive. V9 said, even when she talked to R1 during visits he was always moving and trying to stand. Prior to the fall on 5/30/26, the facility staff initiated 1:1 monitoring for R1. R1 had a sitter before his last fall. V9 stated, the psychiatrist has tried to adjust R1's medication. V9 said, R1 has not been sleeping well at night. V9 said, R1 had a CT (Computed Tomography) scan that documented osteoarthritis. V9 said, R1's fractures came from the impact of his fall.Nurse practitioner progress noted dated 4/29/26 document: Staff report he (R1) is not sleeping well with the trazodone 50 mg at hour of sleep (hs). The patient has a documented history of anxiety and agitation requiring frequent redirection and one-to-one supervision. Of note, on 03/27 during routine rounds, the patient was found sitting upright on the floor in front of his wheelchair, stating he was attempting to go to the bathroom and reported hitting the back of his head during that fall. Patient has do not resuscitate (DNR)/ do not intubate (DNI) status. Requires one-to-one supervision due to anxiety and agitation. 2. Alzheimer's dementia with behavioral symptoms - Patient continues to require one-to-one supervision due to anxiety and agitation. He has to be frequently redirected.Hospital paperwork 6/2/26 documents: Diagnosis unwitnessed fall dated noted 5/31/26. Fall from standing. Left C1 lamina fracture. Left C5 transverse process facture. Forehead abrasion (minor) head and elbow injuries.Fall Prevention Program dated 11/28/12 documents: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of the appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.

Based on observation, interview, and record review, the facility failed to follow its incontinence care guidelines by failing to provide timely incontinence care to dependent residents. This applies to 4 of 6 residents (R3, R4, R5, and R6) reviewed for incontinence care in a sample of 6.The findings include:1.R3 is a [AGE] year-old female admitted with cognition intact as per the MDS (minimum data set) dated 3/6/26. MDS also documented that R3 is dependent on toilet hygiene.On 6/2/26 at 10:10 AM, R3 was observed in her bed with a feces smell upon entrance, and R3 stated, They changed me earlier in the morning at around 4:00 AM by the night staff. I am waiting to be changed.On 6/2/26 at 10:13 AM, V7 (R3's assigned certified nursing assistant / CNA) checked on R3, and R3 was observed with a urine and feces-soaked wet adult briefs.On 6/2/26 at 10:13 AM, V7 stated, I was on the second floor. During breakfast time, they moved me to the fourth floor, and I didn't get a chance to change my people yet.A review of the care plan documented that R3 was care planned for an alteration in bowel and bladder control with interventions including Monitor for non-verbal cues indicative of need to use bathroom or to be toileted by staff.2.R4 is a [AGE] year-old male admitted with severe cognitive impairment as per the MDS dated [DATE]. MDS also documented that R4 is dependent on toilet hygiene.On 6/2/26 at 10:20 AM, R4 was observed on his bed and stated, I was changed last night, and I am waiting to be changed. I didn't get changed after last night.On 6/2/26 at 10:24 AM, V7 checked on R4, and R4 was observed with urine and feces-soaked bed linen and gown. A review of the care plan documented that R4 was care planned for risk of impaired skin integrity, with interventions including provide incontinence care when needed.3.R5 is a [AGE] year-old female admitted with mild cognitive impairment as per the MDS dated [DATE]. The MDS also documented that R5 is dependent on toilet hygiene.On 6/2/26 at 10:30 AM, R5 was observed in her bed and stated, The ladies (CNAs) are saying I have a sore on my buttocks. I am still waiting to be changed. They changed me last night. I put the call light, and the CNA said she would come and change me, but they didn't change me yet.On 6/2/26 at 10:34 AM, observed V8 (Restorative CNA) checked on R5, and R5 was observed with a soaked incontinent brief with brownish discoloration and a big, healed sacral wound (white scarred tissue).A review of the care plan documented that R5 was care planned for risk of impaired skin integrity, with interventions including provide incontinence care when needed.4.R6 is a [AGE] year-old male admitted on [DATE] with severe cognitive impairment as per the MDS dated [DATE]. The MDS also documented that R6 is dependent on toilet hygiene.A review of the wound assessment report dated 5/27/26 documented a chronic facility-acquired stage 4 wound (5.3 x 8.0 x 0.3 centimeter/cm).On 6/2/26 at 11:10 AM, observed V9 (CNA) checking on R6 and was observed with a heavy, wet incontinent brief with mild brownish discoloration.A review of the care plan documented that R6 was care planned for bowel and bladder incontinence with interventions including Check as required for incontinence. Wash, rinse, and dry the perineum. Change clothing as needed after an incontinence episode.On 6/3/26 at 11:10 AM, V4 (Wound Care Director) stated, It's very crucial to provide timely incontinent care for residents to prevent skin deterioration. Our staff is supposed to provide incontinence care for at least 2 hours. Prolonged exposure to feces/urine can cause skin irritation or skin breakdown.A review of the facility's Incontinence Care policy, revised on 4/20/21, documents the guidelines: Incontinence residents will be checked periodically in accordance with the assessed incontinence episode, or approximately every two hours, and provided perineal and genital care after each episode.The facility presented the Pressure Ulcer Prevention policy dated 1/15/18, document guidelines:Maintain clean/dry skin during daily hygiene measures.Inspect the skin several times daily during bathing, hygiene, and repositioning measures.

Based on observation, interview, and record review the facility failed to ensure that the LALM (Low Air Loss Mattress) was on the right setting (while in use) and failed to implement preventive interventions to prevent further decline for two (R6 and R7) of four residents. These failures affected R6 and R7 and have the potential to affect all 39 residents using LALM in the facility.Findings include:On 04/01/2026 between 10:51am to 11:06am, during R6's wound care observation with V7 (Wound Care Director), V14 (Wound Care Nurse), and V15 CNA (Certified Nurse's Aide) / Wound Care Aide. R6 observed on a LALM (Low Air Loss Mattress) set between 130lbs to 180lbs. V7 opened R6's wound site on the sacrum. The wound had a reddish color around the wound bed and blackish color in the center. V7 stated, The wound site is bruised. V7 stated, it might be from pressure at the site. Surveyor asked whether R6 would benefit from repositioning and relieve of pressure. V7 laughed and said, Yes. The surveyor asked V7 what was R6's weight. V7 stated, R6's weight is between 120lbs and 125lbs.On 04/01/26 between 11:17am to 11:30am, during R7's wound care with V7, V14 and V15. R7 was observed in the bed on a LALM set at 80lbs to 130lbs. The surveyor asked regarding the facility policy / protocol on use of LALM regarding the setting. Both V7 and V14 stated, the LALM should be set according to the weight of the resident. R7 stated, I'm about 120lbs. Surveyor asked what the right setting for R7 LALM would be. V7 stated it is set between 80lbs to 130ls which is the correct setting for R7.On 4/1/2026 at approximately 12:10pm, medical record showed recorded R7's weight history and it showed documentation that R7's weight was 136lbs. V2 DON (Director of Nurse's) who was present at the time stated the facility policy/ protocol is to set the LALM according to the weight of the resident.On 4/1/2026 at 12:50am, V7 was shown the LALM setting on R6's bed and V7 stated I will have to educate all these aides and nurses (nursing staff) about the setting on these mattresses. When asked about how often the settings should be checked. V7 stated, at least every shift and the floor nurses should make sure the settings are right. V7 stated, if the settings are wrong, it defeats the purpose of the LALM has been used for, which is to aid healing and prevent developing more pressure wounds.On 04/6/2026 at approximately 3:4pm, when V29 (Wound Care Physician) stated, if the LALM setting is not set correctly, it can affect them in some cases; patients can get more wounds. V29 stated, the purpose of LALM is to relief pressure on the pressure points and redistribute weights.R6's MDS dated [DATE] scored R6 BIMS as 01 indicating that R6 is cognitively impaired.R7 's medical record showed that R7 was admitted to the facility on [DATE] and the MDS is in progress.R6 and R7's medical record EPOS (Electronic Physician Order) showed physician order to check the setting on the LALM. This order was not followed.On 04/02/2026 at approximately 1:15pm, R7 LALM was set between 80lbs and 130lbs. V7 who was present at the time stated I just told them to check all these setting on all the residents on LALM and shook her head. V7 stated, in addition R7's LALM should be set between 130lbs and 180lbs.On 04/01/2026 at approximately 3:08pm, the facility presented the manual for setting the LALM and that documents that in general the pump and mattress is high quality and affordable air mattress system suitable for medium and high-risk pressure ulcer treatment. They have been specifically designed for prevention of bedsores and offer an affordable solution to 24-hour pressure area care. Intended use listed includes but not limited to reduce the incident of pressure ulcers while optimizing patient comfort.

Based on observation, interview, and record review the facility failed to ensure insulin medication was stored in a locked medication cart when not in visual proximity of the nurse. This failure affected one (R3) of four residents whose insulin medication was left at bedside without a physician order. This failure has the potential to affect 37 residents residing on the 2nd floor in the facility. Findings include:R3's medical record listed diagnoses includes but is not limited to Type 2 diabetes mellitus with foot ulcer, other acute osteomyelitis right ankle and foot, type 2 diabetes with hyperglycemia, and anemia.R3's MDS (Minimum Data Set) scored R4's BIMs as 15 cognitively intact.On 03/31/2026 at 12:55pm, R3 observed sitting in wheelchair in the room. On R4 bedside table noted an insulin syringe with a liquid solution. R4 stated that it is insulin, the nurse left it on that table since the weekend and none of them came to pick it up. At 1:00pm, When this was shown to V30 LPN (Licensed Practical Nurse) and was asked about the facility policy/protocol on medication administration. V30 identify the solution in the syringe as insulin 20units and stated that I am not the nurse that left it there, it should not be left on the table. At 1:05pm, V30 stated that no medication should be left at the bedside without Doctor's order and R4 is not on any self-medication administration program. The surveyor asked how often rounds are made and whether this includes making sure the resident environment is hazard free. V30 stated we are not supposed to leave medication and sharps object around in the room.On 03/31/2026 at 1:11pm, V2 DON (Director of Nurse's) was made aware of this observation and spoke with V30 about what happened. At 1:16pm, V2 stated that this should never happen, syringes and medication should never be left in patient room without physician order.R3 physician order showed orders for Insulin Lispro injection solution 100UNIT/ML (insulin Lispro) inject 16 units subcutaneously with meals for diabetes give 16 units with meals 3x (three times) a day with start date 3/19/25. Humalog solution 100UNIT/ML solution injected as per sliding scale.Review of MAR from 03/25/2026 to date 03/31/2026 showed insulin were documented as given with no documentation that R3 refused insulin or was drawn and not given. The facility policy titled Administration procedures for all medications documents that the policy purpose is to administer medications in a safe and effective manner. Listed procedures include but are not limited to if resident refuses medication, document, and refusal on MAR (Medication Administration Record).

Based on observation, interview, and record review, the facility failed to implement fall prevention intervention for a resident at risk for falls. This failure affected one (R5) resident reviewed for falls in the total sample of 5 residents. Findings include: On 03/20/2026 at 11:12am at the nurses' station with V6 (Certified Nursing Assistant), the Call Device monitoring screen indicated Alarm 24 minutes in R5's room and bed. On 03/20/2026 at 2:46pm, V6 stated the 24 minutes on the screen of the call device monitoring system means the call device was activated 24 minutes ago. On 03/20/2026 at 11:21am, there was a leaf beside R5's name. R5 was not in the room. On 03/20/2026 at 11:25am, R5 was seated on a wheelchair across the nurses station with other residents. R5 was wearing gray pants. Inquiring about his call device, R5 stated he had been waiting for 30 - 40 minutes for someone to respond to his call device; he got impatient and got the pants from his closet, put on the pants by himself, but he could not pull the pants all the way up and he was not covered from his behind. R5's pants waist band was on the level of his buttock, and his incontinent brief was visible. R5 stated he could not pull the pants up. R5 stated he did not get the help that he needed and still needed to put his socks on. R5 was wearing shoes with no socks on. On 03/20/2026 at 11:34am, V10 (Certified Nursing Assistant) stated he just got done helping a resident. V10 stated he checked him (R5) at 9am and he did not need anything at that time. V10 stated a resident should not be waiting for 24- 40 minutes because they need help. V10 stated the leaf by his name means he is a fall risk and if he (R5) activated his call device because he needed something, he (V10) should have answered the call device so he (R5) would not fall trying to get it for himself. V10 stated he (R5) uses sliding board to transfer. And he did not transfer him today. Inquiring if he got the gray pants for R5. V10 stated he did not get the pants for him; somebody might have gotten the pants for him. On 03/20/2026 at 11:49am inside R5's room, there was a sliding board on top of R5's bed. V10 stated he was not around when he (R5) transferred from the bed to his wheelchair; and during transfer using the sliding board, somebody should be supervising him so he would not fall. On 03/20/2026 at 11:52am with V10, R5 stated no one supervised him while he transferred himself using the sliding board and no one assisted him in getting his pants from his closet. R5 was not able to raise his left upper extremity and stated his left extremity had been weak for 4 years.On 03/21/2026 at 3:26pm, V11 (Evening Shift Nursing Supervisor/RN) stated the leaf by the resident's name on the doorframe means fall precaution, to mark whoever is at high risk for falling. Everybody is at risk for falls, but some are at high risk for falls. Standard precautions include bed in lowest position, call bell within reach, and call bell should be responded to right away. V11 stated if the careplan indicated the resident needed supervision, the expectation is to follow the care plan for the safety of the resident. V11 stated everybody should follow the care plan. If a resident uses a sliding board for transfer and is careplanned for supervision then there should be staff during transfer to maintain the safety of the resident. On 03/20/2026 at 12:54pm, V4 (Assistant DON) stated all residents are at risk for falls. The leaf beside the name of the resident means the resident is at high risk for falls. Interventions are individualized but the basic intervention include making sure the bed is in lowest position, call light and personal items within the reach of the resident, and call light answered promptly. V4 stated twenty four minutes is beyond the range that it should be answered; 24 minutes is kind of a long wait already.On 03/20/2026 at 1:28pm, V5 (Rehab Director) stated he (R5) was discharged from rehab in 10/2025, and OT (Occupational Therapy) marked him as 'Set Up' for upper and lower body dressing. Set Up means staff will take his clothes out of the closet and hand them to him or set them up on bed or on desk. V5 stated the reason for that is because he is wheelchair bound, and he cannot get up on his own. Rehab gives recommendations to restorative, and it is expected of the staff to follow the recommendations made by rehab for safety reason. V5 stated he (R5) is impatient at times. It is the residual from the stroke. V5 stated she (V5) can see it that if he (R5) waited too long for someone to respond to his call device to get his clothing, he would get it himself and it is not safe for him to do that because he may fall. R5's (01/08/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R5's mental status as cognitively intact. Section I - Active Diagnose. I0020. Primary medical condition. 01. Stroke. I8000. Additional Active Diagnoses: a. hemiplegia (paralysis) affecting left non dominant side, contracture right and left knee. Section GG -Functional Abilities. GG0120. Mobility Devices: C. Wheelchair. GG0130. Self-Care. G. Lower body dressing: 03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. R5's (10/5/2025 - 10/28/2025) Occupational Therapy Discharge Summary documented, in part Diagnoses: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Patient will improve ability to safely and efficiently perform LB (lower body) dressing with Supervision or Touching Assistance with use of no adaptive equipment in order to facilitate ability to live in environment with least amount of supervision and assistance and return to prior level of skill performance. Met on 10/20/2025.R5's (10/17/2025 Target Date: 07/02/2026) care plan documented, in part Focus: Has an ADL (Activities of Daily Living) Self Care Performance Deficit related to Hemiplegia, Impaired balance, Limited ROM. Presents with joint limitations to left upper extremity and bilateral lower extremity. Transfers w/sliding board. Uses w/c (wheelchair) as primary source for mobility. Continue program for maintenance. Goal: Will maintain current level of function in ADLs. Interventions: ADL Snapshot: Presents with joint limitations to left upper extremity and bilateral lower extremity. Supervision for Transfers w/ (with) sliding board. Uses w/c as primary source for mobility. Uses sliding board for transfers. Encourage to use bell to call for assistance. R5's (Initiated: 10/04/2022, Target Date: 07/02/2026) care plan documented, in part Focus: Is at high risk for fall R/T (related to) Deconditioning and history of falls and impulsive behavior. Goal: will be free from injury related to falls. Intervention: 11/30 Remind resident to call for assistance before attempting to self-transfer. Encourage resident to call for assistance with needs. Keep call light and desired personal items within reach. R5's (1/8/2026) Quarterly Fall Scale Evaluation documented, in part Score: 41. Category: Moderate Risk for Falling. E. Gait: Weak. F. Mental Status: 2. Overestimates or forgets limits. R5's (03/2026) Documentation of Survey Report (point of care) was reviewed with no entry for the AM shift on 03/20/2026. The (2-2-18) Call Light documented, in part Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. The (11-17-17) Comprehensive Care plan documented, in part Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.The (11-21-17) Fall Prevention Program documented, in part Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The Fall Prevention Program includes the following components: Methods to identify risk factors. Use and implementation of professional standards of practice. Communication with direct care staff members. Standards: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. Safety interventions will be implemented for each resident identified at risk. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Fall/safety interventions may include but are not limited to: At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. Call lights are answered promptly. Transfer conveyances shall be used to transfer residents in accordance with the plan of care.

Based on interview and record review, the facility failed to implement fall preventive measures for a resident who is a 2 person transfer assist due to increased weakness and behaviors. This deficiency affects one (R1) of three residents reviewed for Falls prevention program. This failure resulted in R1 being hospitalized and treated for a Closed Fracture of Left ankle. Findings include:R1 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnoses in part but not limited to: cerebral palsy, unspecified convulsions, spastic hemiplegic cerebral palsy, other disorders of muscle, reduced mobility, vascular dementia, essential hypertension, Paroxysmal atrial fibrillation, gastro-esophageal reflux disease, cardiomyopathy, hypothyroidism, autistic disorder, schizophrenia, bipolar disorder, generalized anxiety, unspecified fracture of shaft left fibula, depression,Facility Reported Incident dated 10/18/25 documents during transfer R1 was assisted by certified nurse aide, R1 was observed sitting on floor with her back to the bed with legs flat on the floor. R1 sustained Left Tibia Fibula Fracture.On 2/7/26 at 10:30AM, R1 said that she recalls when she fell and broke her ankle. R1 said that there was only one certified nurse aide present and was transferring her from bed to wheelchair and that the wheelchair was not positioned correctly and the certified nurse aide grabbed her from under the arms and stood her up and then let go of her from her left side and that's when she slid down to the floor. R1 said she has weakness to left arm. R1 said she was wearing her Ankle Foot Orthosis (AFO) brace and when she slid to floor, she heard a cracking sound and told the staff her leg hurt.On 2/7/26 at 11:27AM, V3 (Registered Nurse) stated she was unsure of what transfer status R1 was prior to the fall, V3 said she was the nurse on duty when R1 fell on [DATE]. V3 said there was only one staff member assisting her with the transfer on 10/18/25. R1 did sustain a fracture from fall. On 2/7/25 at 12:40PM, V5 (Licensed Practical Nurse) stated she was not aware of fall care plan intervention of two person transfer due to increased weakness and behaviors.On 2/7/26 at 1:40PM, V7 (Registered Nurse) stated that for all residents the care plan interventions are to be followed.On 2/7/26 at 2:20PM, V2 (Director of Nursing) stated that her expectations are for care plans to be updated as needed and staff to follow resident's interventions as indicated.On 2/7/26 at 2:35pm, V1 (Administrator) stated that care plans should be updated quarterly, annually and as needed and expect the staff to follow care plan interventions.The Post Fall Observation assessment dated [DATE]- indicating High Fall risk.GG self-care and mobility assessment dated [DATE] chair/bed to chair transfer- Dependent requiring two staff assist.GG- Functional Abilities and Goals assessment dated [DATE]- chair/bed to chair transfer- Dependent- requiring two staff assist.MDS section GG- Functional abilities dated 7/23/325- Putting on/taking off footwear- Dependent requiring two staff assist.MDS section GG- Mobility dated 7/23/25- chair/bed to chair transfer- Dependent requiring two staff assist.Care plan dated 2/22/23 R1 would benefit from use of left Ankle Foot Orthosis (AFO) Brace, related to diagnoses of cerebral palsy, spastic hemiplegic cerebral palsy, vascular dementia. Intervention: Observe for signs/symptoms of pain, discomfort or intolerance.Care plan dated 1/8/24 R1 is at risk for falls r/t gait/balance problems, poor communication/comprehension, history of falling, spastic hemiplegic cerebral palsy exhibits poor judgment exhibited by intentions placing self on floor. Interventions: Moderate to substantial assist x two staff with gait belt for all transfers due to increased weakness and behavior.Care plan dated 1/24/25 R1 has ADL Self Care Performance Deficit related to dementia and disease process of cerebral palsy. Presents with diagnosis of cerebral palsy. Noted with limitations to left foot requiring left ankle foot orthosis brace/boot. Requires mechanical Hoyer lift x two person assist with transfers. Non-ambulatory requires wheelchair for mobility.Care plan dated 4/30/24 R1 requires use of full body lift for transfers. Intervention: Full body lift with two person assist for all transfers. Facility Policy on Fall Prevention Program- revised 11/21/17Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness.Guidelines:The Fall Prevention Program includes the following components:-methods to identify risk factors-methods to identify residents at risk-assessment time frames-use and implementation of professional standards of practice-immediate change in interventions that were successfulPeriodic quality assurance audit activities of records relating to falls that exhibit adherence to facility policies and implementation of the plan of care.Standards:-A fall risk assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines.-A fall risk assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident.-Safety interventions will be implemented for each resident identified at risk.Fall/safety interventions may include but are not limited to:Direct care staff will be oriented and trained in the Fall Prevention Program.Each resident will be screened by a specialist therapist at the time of admission, quarterly, after each fall, as appropriate and with significant change in the residents' mental and functional abilities.Transfer conveyances shall be used to transfer residents in accordance with the plan of care.Facility Policy on Transfer-Manual Gait Belt and Mechanical Lifts- revised 1/19/18Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Residents.Guidelines:5. The transferring needs of residents will be assessed on an ongoing basis and designated into on of the following:2=2 person transfer with gait belt (ONLY when use of mechanical lift is not possible)6. Resident transferring and lifting needs shall be documented in care plans and reviewed via care plan time frame and as needed.

Based on observation, interview and record review, the facility failed to provide necessary assistance for one dependent resident (R149) in accordance with care plan by failing to complete weekly shower/skin assessment as ordered. This failure affected one (R149) of six residents reviewed for Activities of Daily Living (ADL) care. R149 developed a hematoma to her right great toe at the facility, complaint of pain where it was noted R149's wound was infected, and an x-ray revealed a fracture to the right great toe. R149 was treated with oral antibiotics for seven days.Findings include:R149 is a [AGE] year-old female who has resided at the facility since 8/28/2025, past medical history includes, but not limited to hypertensive heart disease, other dysphagia, other reduced mobility, type 2 diabetes, anemia, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side, etc.On 11/17/2025 at 10:30AM, R149 was in her bed, awake and alert but could not answer any questions, resident was able to nod yes and no to some questions. The nurse was outside the door preparing medication for resident, surveyor requested her assistance to assess resident's right great toe, which was noted with no dressing, dry and with some whitish discoloration close to the nail bed. Surveyor asked resident if she still gets dressing to her toe and she shook her head no.Wound care note dated 10/1/2025 documented a facility acquired hematoma to right great toe measuring 2.50 X 2.0 X unknown (L X W X D). Area 5.00cm, volume unknown. Tissue type- blood filled blisters 100%.R149 was assessed as being dependent on staff for all activities of daily living (ADL) needs and always incontinent of bowel and bladder, Behavior assessment indicated that resident does not exhibit any behaviors. Active physician order documented the following: Right great toe: cleanse with normal saline, pat dry and paint with betadine and cover with dry dressing daily and as needed for wound care. Weekly showers/skin assessment, acknowledgement of shower and skin assessment completed. If new skin issue, notify physician, notify family and complete skin assessment form.Care plan initiated 10/1/2025 documented that resident has arterial wound to right great toe, is at risk for delayed wound healing and is at risk for further alteration in skin integrity related to anemia, diabetes, hypertension, and peripheral arterial disease. Interventions include monitor skin during care and report changes, ongoing assessment of wound to evaluate signs of deterioration or improvement, treatment as ordered by physician, etc.Urgent care record dated 10/25/2025, history of present illness documented in part: [AGE] year-old female parented(sic) with right great toe injury discovered 25 days ago by family when they removed resident's socks. Currently patient reports pain to right great toe at the site of injury, pain is worse with touch.X-ray of foot 3 or more view indicated under impression of acute nondisplaced intra- articular fracture of the distal phalanx of the right toe.Diagnosis was listed as cellulitis of right toe, nondisplaced fracture of distal phalanx of right toe, type 2 diabetes. Medication orders: prescribed clindamycin HCL300mg capsule, take 1 capsule by mouth every 6 hours for seven days.Shower sheets for the months of September, October and November indicated that R149 was not receiving showers as scheduled, occasional bed baths, no documented skin assessment and marked mostly as refused.On 11/19/2025 at 12:59PM, V49, Certified Nursing Assistant (CNA) said that she does not have any issues with resident, she works with her on day shift and always assist her with dressing up and brushing her teeth. Resident is usually set up in the bathroom by the sink, and she brushes her teeth by herself. Resident does not refuse ADL care as far as V49 is concerned, she is always pleasant.On 11/18/2025 at 3:05PM, V24 (Wound Care Coordinator) said, nurses are supposed to sign off the skin assessment section of the shower sheet after the CNA finishes the shower if the resident lets them. V24 was asked if the nurses should document resident's refusal in the progress note and she said that she is not sure, that will be the question for the nurses. On 11/19/2025 at 2:15PM, V24 was asked about R149 wound to her great toe. V24 said, resident was being treated with betadine and the wound was being assessed daily by wound care, and they did not notice any signs of infection. V24 added that she was not aware that resident's toe was infected, nor aware of the antibiotic treatment or that she had a fracture.On 11/19/2025 at 9:05AM, V2, Director of Nursing (DON) said, resident had a bump on her toe which started after family gave her a shower and told staff that they accidentally bumped resident's toe on her wheelchair. V2 said that the wound care doctor saw the resident and she was getting treatment for it. V2 added that R149 always refuse ADL care. Surveyor asked V2 if that was care planned and she said that she was not sure. On 10/25/2025, resident's daughter came in, showered the resident, and dressed the resident herself, took the resident out on pass without informing anyone in the facility. While on pass, the daughter took resident to urgent care and they prescribed antibiotics for her, they also did an x-ray that showed a fracture to her right great toe, V2 does not know that resident's toe was infected, or how resident got the fracture.On 11/10/2025 at 12:15PM, V1 (Administrator) said that she investigated and reported resident's injury as an injury of unknown origin, but it was not unsubstantiated because resident did not complain of pain before the family took her out on pass. The injury started as a redness which occurred after family gave resident a shower and accidentally bumped her feet on her wheelchair V1 said that the family reported the incident to the nurse. On 11/19/2025 at 12:02PM, V51 (LPN) said that she worked 3 to 11pm shift on 10/25/2025, R149 was out on pass at the beginning of her shift. The daughter came to the nursing station later that evening and handed her a bottle of medication, stating that R149 has an infection to her toe and also has a fracture.V51 said that family usually gives resident a shower and one day, the daughter told V51 that she accidentally bumped resident's toe on her wheelchair, that's how she got the injury. Surveyor asked V51 if she documented the reported incident by the family and she said no. V51 then changed her story stating that the family did not report that to her, but she just assumed that since they always give her a shower, that must have been the cause of the injury. V51 added that she is not sure how the resident sustained the fracture and was not aware that her toe was infected until the daughter came back from urgent care with the antibiotic.Bathing-shower and tub bath policy dated 1/31/2018 documented its purpose as to ensure resident's cleanliness to maintain proper hygiene and dignity. Guideline- a shower, tub bath or bed/ sponge bath will be offered according to resident's preference two times per week, or according to resident's preferred frequency and as needed or requested. Document bathing and assistance provided in the electronic health record, including pertinent observations.

Based on interview and record review the facility failed to administer medication as ordered for one resident (R77) reviewed for medication administration. This failure affected one resident and has the potential to affect all residents residing on the 2nd floor.Finding includes:R77's medical record Admissions Record showed documentation that R77 was originally admitted on [DATE] and current admission date is 10/29/2025. Listed diagnosis include but not limited to Acute and Chronic Respiratory failure with hypoxia, metabolic Encephalopathy, encounter with Hospice care, other reduced mobility, other specified disorders of muscle, pressure induced deep tissue damage of sacral region, pressure induced deep tissue damage of other sites, presence of pacemaker, unspecified atrial fibrillation, and type 2 diabetes mellitus with diabetic neuropathy.R77 physician Order Summary Report showed that R77 has an order dated 11/13/2025 for Ativan oral tablet 0.5mg (Lorazepam) with instruction to give 0.5mg tablet by mouth every 6 hours for anxiety, agitation: give 2 tabs (tablets).R77's MAR (Medication administration Record) dated 11/1/25 to 11/30/2025 showed the same and instruction.R77's Controlled Drug Receipt/record/Disposition Form presented showed that on 11/14/25 R77 was administered two tablets of lorazepam tablet 0.5mg to equal 1mg and from 11/14/25 from 6pm only one tablet was administered instead of two tablets as ordered until 11/18/25 at 12 noon.R77' s MAR (Medication Administration Record) showed that the medication was signed out as if two tablets of lorazepam 0.5mg had been administered as ordered.On 11/18/2025 at 11:49am, V43, LPN (Licensed Practical Nurse) stated, we told (V2 (Director of Nursing) about it as you were looking at the narcotic book. I don't know why others (nurses) are giving him one tablet (referring to Ativan 0.5mg) because the order was to give 2 tablets to make it 1mg. Surveyor asked V43 can the nurses decrease or increase medication dosage without a physician order. V43 stated, No, the doctor must order it. At approximately 12:20pm, V43 administered 2 tablets of Ativan 0.5mg to R77 for anxiety as ordered. V43 stated (R77) Ativan has been changed from Ativan 0.5mg to Ativan 1mg. We (Licensed Nurses) are to give 2 tablets of 0.5mg to make it (equal) 1mg. V43 stated, medications are supposed to be signed out as administered to show the dose given and it should be signed out after the patient has taken the medicine.On 11/18/2025 at approximately 2:09pm, V2 (DON) stated, medications should be given as ordered by the physician or the NP (Nurse Practitioner.) V2 stated, R77's order for Ativan was changed on 11/13/2025 from 0.5mg to 1mg but for some reason the nurses are not giving R77 two (2) tablets of the 0.5mg as ordered and instructed. V2 stated, it is written in the MAR and the medication card and that is an error on the nurse's part.The facility policy on Physician Orders with revision date 1/31/18 documented that the purpose is to provide general guidelines when receiving, entering, and confirming physician or prescriber's orders (a prescriber is noted as physician, nurse practitioner, and a physician's assistant).Listed guidelines includes entering the order in the resident's chart, medication orders should include but not limited dose, time and frequency. Verbal and telephone orders will be documented as such in the electronic medical record.Facility Medication Administration policy presented with revised date1/1/2015 documented that medications must be administered in accordance with a physician's order that includes but not limited to right dosage, and right medication. Under the title Medication treatment errors documented in part that if a medication error occurs, this, the licensed nurse will immediately notify the attending physician, describe the error and resident response, identify the error on the 24-hour report. The policies documented that any discrepancy must be reported immediately to the Director of Nursing or his or her designee.

Based on interview and record review, the facility failed to transcribe physician orders for comfort care medications for a resident admitted to hospice care services. This failure affected one (R1) of five residents reviewed for physician orders and resulted in R1 having untreated pain for several days before expiring in the facility. Findings include: R1 was originally admitted to the facility [DATE] with diagnoses that included but are not limited to malignant colon cancer. According to R1's electronic health record, progress notes of [DATE] indicate R1 went to an outpatient oncology appointment and was hospitalized with a diagnosis of adult failure to thrive. While in the hospital, and due to R1's sudden decline in health, R1's healthcare proxy elected for R1 to admit to hospice services upon returning to the facility. Consent for hospice services was signed in the hospital on [DATE]. R1 returned to the facility [DATE]. According to nurse progress notes, V3 LPN (Licensed Practical Nurse) received R1 upon arrival, and transcribed orders received from the hospital. An order for hospice services was written on the Physician's Order Sheet [DATE]. On [DATE] at 9:10am V9 (R1's Representative) said they went to visit R1 on [DATE]. V9 stated walking in R1's room, V9 noticed that R1's face was contorted in pain, and R1 was gripping the sheets. V9 stated, since the hospitalization , R1 was confused and would often say no to anything R1 was being asked. When V9 saw R1's presentation, V9 immediately went to find a nurse, however the nurses were not immediately available at the nursing station. V9 saw an unidentified staff member enter the room and relayed the concern of R1 showing overt signs of pain. V9 and the staff member found the nurse on duty (V10 LPN), V9 stated V10 relayed that R1 had morphine on hand and showed it to V9. However, V10 stated there was no order written and therefore could not administer it to R1. V9 stated, the nursing manager (V2 Director of Nursing) got involved and got an order for R1 to receive the medication and the nurse gave it. During this interview, V9 began crying and stated my biggest heartache is that [R1] sat there in pain before he died in the facility. [R1] had been [in the facility] since Sunday, and Thursday was the first time he got morphine and then on Friday ([DATE]), [R1] died . According to hospice notes, R1 was assessed by a hospice nurse and admitted to hospice services the following day of readmission on [DATE]. Written hospice orders included comfort kit medications orders which included morphine sulfate for pain, lorazepam for anxiety and restlessness and acetaminophen suppositories for fever and pain. Hospice RN (Registered Nurse) and facility nurse V7 LPN signed that orders were reviewed and received. At the time of this survey, review of Physician's Order Sheet for [DATE] did not include any transcription of the hospice orders for medications. V6 is representative from the hospice company caring for R1. On [DATE] at 3:40pm V6 stated R1 was transferred to the facility over the weekend, and the (hospice) nurse came to assess and admit R1 to hospice the following day [DATE]. While the nurse was at the facility, medication and other orders were confirmed with the facility nurse on duty for R1. V6 stated the nurse was identified as V7 as evidenced by name and signature on the admission forms. V6 stated the hospice company provides the comfort kit medications from a collaborating pharmacy and the medications usually arrive before or at the time the admitting nurse comes so that the medications are available to be reviewed during admission. V6 also provided a pharmacy sheet manifest that listed V8 LPN as receiving medications from the hospice pharmacy. The medications delivered included five milliliters of Morphine Sulfate 20mg/ml (milligrams/milliliter) solution received by V8 on [DATE] at 1:49pm. Hospice Comprehensive Assessment notes that the admitting hospice nurse's time in was for 1:50pm, and time out 3:00pm. Hospice Chaplain noted visiting R1 on [DATE]. Hospice Support Services Log written by the chaplain included a care plan open for pain. During the Chaplain visit R1 was noted to exhibit signs of pain: [R1] reports no, grimacing with anticipation. R1's Nursing Progress Note dated [DATE] at 5:32am stated [R1] observed with shortness of breath while lying flat, resident repositioned, head of bed elevated Vital signs taken, [oxygen] given via [nasal cannula]. [R1] appears comfortable at this time, will continue to monitor. Resident recently enrolled in hospice services. will continue to monitor. On [DATE] at 11:53am V2 DON (Director of Nursing) stated, they were not aware of any concern related to R1's pain medication not being available, however remembered helping the nurse on duty with orders on [DATE]. V2 stated the nurse (V10 LPN) was fairly new and we had to call hospice directly for the orders because R1 didn't have any orders for the morphine documented in the electronic health record. V2 stated they didn't know if the medication was available, and I didn't ask but I did put the orders in the [electronic health record]. V2 went on to say, at the time of the hospice nurse's assessment of the residents admitting to hospice care, facility nurses are expected to review any new orders provided by hospice relay them to the primary provider and transcribe the orders onto the Physician Order Sheet. Nurses are then expected to write a progress note indicating this action. Working nursing schedules were reviewed and confirmed V7 LPN and V8 LPN as the nurses working R1's unit the 7am-3pm shift on [DATE]. On [DATE] at 3:33pm V7 LPN stated the unit was short one nurse that day and it was likely very busy. V7 recalled taking care of R1 on [DATE] but did not recall receiving hospice orders. On [DATE] at 12:07pm V8 LPN stated they could not recall working the unit that morning and did not recall receiving medications for R1. The Physician Order Sheet indicated three orders documented by V2 on [DATE] at 11:03 for Morphine Sulfate: Morphine Sulfate (Concentrate) Solution 20 mg/ml (milligram/milliliter) Give 5 mg by mouth every 2 hours as needed for moderated Pain give 5mg; Morphine Sulfate (Concentrate) Solution 20 mg/ml Give 10 mg by mouth every 2 hours as needed for Severe Pain Give 10mg(0.5ml); Morphine Sulfate (Concentrate) Solution 20 mg/ml Give 5 mg by mouth every 1 hours as needed for dyspnea/ air hunger/ shortness of breath/ respiratory rate give 5mg. Policy for Transcription of Physician Orders no revision date states in part: Purpose: 1. To establish the procedure by transcribing new physician orders. 2. To document and give clear indication that physician orders have been processed and action taken. Admission Protocol or Return From Hospital Stay: 1. Transcription of physician order: a. Carefully, review transfer record and discharge summary from the hospital or the transfer record from another health care facility. B. The licensed nurse should notify the physician of the resident's admission, clinical condition and findings, review and clarify transfer orders and previous orders, as applicable. C. After each order is entered in the Physician Order tab of the chart, check that all orders were entered correctly. D. After physician verification, the licensed nurse completes a progress note that denotes the physician is aware of the admission and that the orders were verified. 6. Medication and treatment orders are to be transcribed in the physician order tab of the electronic medical record. Directions must be understandable (without abbreviations other than the approved abbreviations) by all staff members who are responsible for medication and treatment administrations. Hospice Services Agreement contract with the facility signed [DATE] states in part [hospice provider] shall also provide all prescription drugs, pharmaceuticals, medical equipment and supplies relating to a resident Hospice Patient's terminal illness as may be specified in such Resident Hospice Patient' Plan of Care. Services to be provided by Nursing Facility: A. Room and Board. 1. Nursing Facility shall provide Room and Board services in the form of personal care services to each Resident Hospice Patient. It is nursing Facility's responsibility to continue to furnish 24-hour room and board care, meeting the personal care and nursing needs that would have been provided by the primary giver at home at the same level of care provided before hospice care was elected. Such Room and Board services shall include but not be limited to such services as: 3- Administration of medication as prescribed in the Plan of Care.

Based on interview and record review, the facility failed to follow their grievance policy by not acknowledging a concern written by a resident representative. This failure affected one of one (R1) resident reviewed for grievances. Findings include: R1 was originally admitted to the facility [DATE] wit diagnoses that included but are not limited to malignant colon cancer. According to R1's electronic health record, progress notes of [DATE] indicate R1 went to an outpatient oncology appointment and was hospitalized with a diagnosis of adult failure to thrive. While in the hospital, and due to R1's sudden decline in health, R1's healthcare proxy elected for R1 to admit to hospice services upon returning to the facility. R1's consent for hospice services was signed in the hospital on [DATE]. R1 returned to the facility on [DATE] and was admitted and assessed by hospice care services on [DATE]. Hospice orders were written at the time of assessment, however, were not transcribed to R1's electronic health record. As a result, R1 did not receive any of the comfort medications ordered, from [DATE] to [DATE]. On [DATE] at 9:10am V9 (R1's Representative) stated they went to visit R1 on [DATE]. V9 stated walking in R1's room, V9 noticed that R1's face was contorted in pain and R1 was gripping the sheets. V9 went on to explain that there was confusion among the nursing staff because there was medication available to give R1, however no orders were transcribed in the chart. During this interview, V9 began crying and stated my biggest heartache is that [R1] sat there in pain before he died in the facility. [R1] had been [in the facility] since Sunday and Thursday was the first time he got morphine and then on Friday, [R1] died . V9 stated these concerns were expressed to V1 Administrator via email a few weeks ago, however no facility staff have reached out to address the concerns as written. On [DATE] at 3:30pm V1 administrator stated regarding Grievances, any resident, family member or outside person is able to relay a concern to the facility staff. V1 stated no matter if the concern came via phone call, face to face or email the concern finds its way on a grievance form. V1 was unaware of any concerns related to R1 and had not received any documented concerns since R1's passing. V9 provided the surveyor a forwarded email sent to V1 Administrator on [DATE]. The email address was confirmed as provided during this survey. Facility grievance forms were reviewed from [DATE] to current and no grievance was filed for V9. Facility Policy Grievances revised [DATE] states in part; Purpose: To ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. Guidelines: Grievances may be filed orally (meaning spoken), in writing, or anonymously. Grievances may also be filed anonymously through the Corporate Compliance Hotline. Contact information for the Corporate Compliance Hotline shall be posted in prominent locations through the facility. All written grievances shall include: The date the grievance was received; A summary statement of the grievance, Department assigned to investigate; Steps taken to investigate the grievance; Summary of the pertinent findings or conclusions regarding the concerns(s); Statemen as to whether the grievance was confirmed or not confirmed; Corrective action taken or to be taken by the facility as a result of the grievance, including measure taken to prevent further potential violations of any resident right while the alleged violation is being investigated. ; The date the written decision was issued to the resident or the complainant. Every effort shall be made to resolve grievances in a timely manner, usually within 5 business days (excludes weekends and holidays). Under certain circumstances, additional time may be needed to complete an investigation and implement measures to resolve the grievance. In such cases, the resident or complainant should be notified of the extension. Copies and results of grievances filed shall be maintained for a period of no less than 3 years from the issuance of the grievance decision.

Based on interview and record review the facility failed to ensure resident safety by failure to provide two persons assist to a totally dependent resident (R121) when providing incontinence care. This failure resulted R121 falling from bed that required a visit to the hospital for evaluation and repair of a laceration to the scalp which needed three staples. This deficiency affects one (R121) of three residents in the sample of 32 reviewed for Resident safety/Fall Prevention Program. Findings include: On 11/20/24 at 10:03AM, V30 Family member stated the facility failed to provide adequate care and supervision causing R121 to fall while receiving care. R121 fell from bed resulting in a head laceration. R121 legs are contracted and laid still. On 11/20/24 at 10:30AM, V1 Administrator and V2 Director of Nursing (DON) stated that R121 fell from bed on 11/4/24 during incontinence care provided by V29 Certified Nursing Assistant (CNA). On 11/20/24 at 10:48AM, R121 lying in bed with low air loss mattress. She (R121) is nonverbal. R121 has a Tracheostomy connected to oxygen at 3LPM (liters per minute). R121 has Gastrostomy tube connected to Glucerna 1.2 feeding tube at 65ml/hour. She is totally dependent of ADLs (Activity in Daily Living) and transfers. Review of R121's incident report submitted to the State Agency on 11/5/24 indicated: Date of incident: 11/4/24 at 6:30AM. Witnessed fall with physical harm or injury. V29 CNA written statement indicated she was providing ADL care to resident. As she rolled R121 over to provide incontinence care she began to slide out of the bed. She called for assistance from V25 LPN (Licensed Practical Nurse). Observed R121 on the floor in a side lying position. Noted moderate blood to the posterior scalp. Bleeding controlled. No loss of consciousness (LOC) noted. Neuro check initiated with no deviation from baseline. ROM (range of motion) done to all extremities and were within normal limit. Physician made aware and ordered to send R121 to hospital for evaluation. V30 Family member notified. R121 returned to facility with three staples to right lateral head. R121's hospital records dated 11/4/24 indicated: Witnessed fall from her bed and hitting her head. Per EMS (Emergency medical services), staff reports that the R121 was being cleaned up by staff and she rolled off her bed. Staff reports R121 has no LOC and has laceration to the head. R121 non-verbal at baseline. Clinical impression: Laceration of scalp, Fall. Physical exam: 2 cm laceration to the right sided parietal scalp without active bleeding or surrounding erythema. Laceration repair: three staples to right parietal scalp. R121 is readmitted on [DATE] with diagnoses listed in part but not limited to Anoxic brain damage, Chronic respiratory failure with Hypoxia, Tracheostomy, Gastrostomy, Dysphagia. Comprehensive care plan indicates she has an ADL self-care performance deficit related to disease process of anoxic brain damage, dependent for ADLs and mobility, incontinent of bowel and bladder. She has contractures to all extremities. She is at risk for falls and fall related injuries related to decreased mobility and impaired balance. Most recent MDS/Resident assessment dated [DATE] section GG Functional abilities: GG0130 Self-care indicated: Toileting hygiene, Shower/bathe self and Personal hygiene coded as 01-Dependent- helper does all of the effort, Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. GG0170 Mobility indicated: Roll left and right coded as 01- Dependent- helper does all of the effort, Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. On 11/20/24 at 1:48PM, V1 Administrator stated that they don't have policy on Resident safety. On 11/21/24 at 10:22AM, V25 LPN stated he was working with R121 when she had the fall incident while V29 CNA was providing incontinence care. V25 stated that R121 is totally dependent in ADLs and needed two person assist with mechanical lift transfers. V25 stated that he did not witness the fall incident. V25 stated that V29 CNA should have pulled R121 toward her or closer to her instead of rolling R121 away from her for safety. On 11/21/24 at 10:49AM, V26 Nursing Supervisor 11-7 shift stated she was called by V25 LPN to R121's room. V26 stated, she observed R121 in a lying position and observed laceration to scalp. V26 stated they controlled the bleeding. Physician and family were notified of the incident. R121 was sent to the hospital for evaluation. R121 returned with staples to the lacerated scalp. V26 stated that they did in-service the nursing staff of proper position/transition during incontinence care. V26 stated that for resident safety, CNA should get assistance of two persons to assist dependent resident for incontinence/ADL care. V29 CNA should pull R121 towards/ closer to her to prevent R121 slipping from edge of the bed. On 11/21/24 at 11:23AM, V29 CNA stated that she was providing incontinence care with R121, when she slid off the bed. V29 stated that she should have pulled R121 towards/closer to her instead of rolled her away from her placing her at edge of the bed. On 11/21/24 at 12:02PM, V27 MDS/Restorative Nurse stated that she did the MDS/Resident assessment of R121. V27 stated R121 is totally dependent with ADLs and transfers. Section GG functional abilities indicated that she needs two assists with bed mobility- roll to left and right side and personal hygiene and grooming. On 11/21/24 at 1:20PM, V2 DON stated that they did in-service the nursing staff regarding proper and safe positioning and bed mobility to dependent resident such as ensuring that there is as adequate number of caregivers present to safely position or move the patient. V2 stated, when providing ADLs/incontinence care in bed that staff should roll/pull the resident toward /closer to them to prevent placing resident at the edge of the bed and avoid slipping out of bed. Facility unable to provide policy on Resident Safety. Facility's policy on Fall Prevention Program revision 11/21/17 indicates: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Facility's tips for positioning a patient in bed: The process of positioning a patient in bed should be smooth, safe, and comfortable for both the caregiver and patient. * Ensure that there is an adequate number of care givers present to safely position or move the patient.

Based on interview and record review the facility failed to prevent a pressure injury from developing for an at-risk resident for 1 of 3 residents (R4) reviewed for pressure in the sample of 8. The findings include: R4's Admission Skin Check done on 8/15/24 shows R4 had a right above the knee wound and no other wounds were documented. R4's Shower sheet dated 8/27/24 shows open sore with the coccyx area circled on the diagram. On 9/20/24 at 11:05 AM, V12 Wound Coordinator Licensed Practical Nurse stated R4 had a full body assessment done on admission and only had a surgical wound due to right above the knee amputation. V12 stated R4 was alert and oriented to person and place and was incontinent. V12 stated R4 was assessed as a risk for pressure due to his reduced mobility and incontinence. V12 stated on 8/27/24 R4 was found to have a pressure injury to his coccyx. V12 stated initially it was assessed at a Stage 2 but when the wound physician assessed it one week later, it was a Stage 3. V12 stated R4 not being turned and repositioned or not having incontinence care provided could cause a wound to develop. On 9/20/24 at 10:17 AM, V4 Certified Nursing Assistant stated R4 did not like being wet and would call and let you know when he needed to be changed. V4 stated R4 would complain to her about night shift not changing him. V4 stated R4 didn't like to be wet at all. V4 stated R4 had no wounds other than his surgical knee. V4 stated she was off for the weekend and when she came back the next week R4 had a wound on his bottom and she reported it to the nurse. R4's Wound Assessment on 8/28/24 shows facility acquired, pressure, Stage 2 to coccyx with measurements 2.50 x 4.50 x 0.10 cm with 70% pale pink non-granulating skin and serous exudate. R4's Wound Physician Note dated 9/4/24 shows Stage 3 pressure injury to coccyx full thickness 2.2 x 1.3 x 0.2 cm with moderate serous exudate. R4's Care Plan shows R4 has an amputation above the right knee with intervention to change position frequently to prevent respiratory complications, prevent dependent edema and skin pressure areas. This same care plan shows R4 is at risk for alteration in skin integrity due to alzheimer's/dementia, arteriosclerosis/atherosclerosis, diabetes, fragile skin, incontinence of bowel, incontinence of urine, limited joint mobility, muscle wasting, and peripheral vascular disease with interventions to keep skin folds clean and dry and moisture barrier cream/ointment after each incontinence episode.

Based on observation, interview, and record review, the facility failed to protect resident rights to be free from physical abuse by staff. This failure affected two (R1 and R2) of four residents reviewed for abuse and resulted in R1 sustaining swelling and redness to her left eye and being transferred to a local hospital to rule out orbital fracture and R2 sustained redness to his face after being slapped by a staff. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, past medical history includes, but not limited to: cerebral palsy, spastic hemiplegic cerebral palsy, paroxysmal atrial fibrillation, vascular dementia, essential primary hypertension, encounter for attention to colostomy, anemia, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, hypotension, etc. On 9/5/2024 at 10:25AM, R1, who just returned from the hospital was observed in her room, awake and alert and was being assisted with ADL (activities of daily living) care by V10 (restorative aide). R1 was asked why she went to the hospital, and she R1 stated, the two CNA's (certified nursing assistant) hurt me, one was on the right side and was twisting my hand and fingers, the other was on the left side hitting me with the remote control. R1 tried to demonstrate what happened by twisting surveyor's fingers and used her bed remote control to demonstrate how the CNA hit her face. R1 was noted with some dark purplish bruising to her right hand, some redness to her left cheek under the left eye and a little swelling around the left eye. Progress note dated 8/31/2024 at 9:32AM documented that R1 was noted with swelling and discoloration to her left eye, patient complained of some pain and pain meds were given. Attending physician who was on ground was notified, ordered for the resident to be sent out to a local hospital. Physician progress note dated 8/31/2024 at 12:10PM states in part: patient seen and examined, patient is complaining of swelling and pain on the left eye patient stated that somebody had hit her. No fever or chills, patient states she cannot move her left eye, will send patient to the hospital for evaluation of possible orbital fracture. Facility reported incident dated 8/31/2024 documented in part that R1 was noted with discoloration to her left eye, and she described the two staff that she alleged caused her the injury while providing her with ADL care. Police report dated 8/31/2024 documented that police responded to the facility for a delayed battery report. In the report, R1 was named as the victim and V6 (CNA) and V7 (CNA) named as the suspects. According to the police report, R1 reported that one staff slapped her across the face and the other one twisted her right hand and fingers, resident was noted with discoloration and swelling to her face and bruising to her right hand. Hospital record dated 8/31/2024 documented as chief complaint that R1 presented with an allegation of being hit in the face with a remote and staff twisting her fingers at the nursing home. 9/4/2024 at 1:22PM, V4 RN (registered nurse) stated that she came to work on 8/31/2024 and was making rounds around 7:15AM when she noticed R1's leg out of the bed, she asked another nurse to come and help her reposition resident. R1 reported that she was abused by two staff members (CNAs), but she does not know their names. V4 had not seen or heard R1 making such an allegation in the past. V4 confirmed that R1 was complaining of pain to her hands and left eye. V4 noticed some bruising and swelling to R1's left eye and bruising to her left hand that was purplish/blue in color. 9/4/2024 at 2:09PM, V8 MD (medical doctor) stated that he came to the facility to see R1 and noticed some swelling in her left eye and that the resident stated that 2 CNAs abused her and she was complaining of pain. V8 also noted small redness inside resident's eye and decided to send her to the hospital for further evaluation. V8 added that the redness and swelling also could result from an infection or abuse but he is not sure, he did not check resident's hands, he saw the resident before going on vacation and she did not have the redness. V8 added that R1 has never made any abuse allegation in the past, the redness and swelling was new and resulted from a recent incident. 9/4/2024 at 3:41PM, V2 DON (director of nursing) stated that she was called by a staff between 7:00 - 8:00AM and was notified that R1 said that she was hit by someone. V2 went to resident's room and noted some discoloration to her left eye. 9/4/2024 at 3:59PM, V1 (Administrator) stated that R1 has a behavior of throwing herself on the floor, removing her colostomy bag, etc. to get attention. Both CNAs denied hitting R1. Review of medical records did not show any documentation of R1 ever accusing any staff of abuse before this incident. R2 is an [AGE] year old resident with past medical history that includes: metabolic encephalopathy, acute kidney failure, unspecified injury of head, urinary tract infection, major depressive disorder severe with psychotic symptoms, hyperlipidemia, dysphasia oropharyngeal phase, alzheimer's disease, parkinson's disease, depression, anxiety disorder, etc. On 9/3/2024 at 11:15AM, R2 was observed in his room, awake, alert, and oriented with some confusion. R2 recalled being slapped on his face by someone but does not recall exactly what happened. Progress note dated 8/9/2024 documented that resident was noted with redness to the side of his face, resident denied pain, MD and family notified. Facility reported incident dated 8/9/2024 documented that the administrator was notified that R2, and a nurse practitioner (V11) were involved in a physical altercation, body assessment completed, resident noted with redness to right side of face, no complaints of pain, MD, family, and police were notified, police report completed. The report concluded that R2 was abused by V11 who was reported to her employer group and is no longer employed at the facility. Police report stated that police responded to the facility for a delayed battery. R2 was listed as the victim and V11 (Nurse Practitioner) as the offender. The same report documented that V11 admitted being at fault, stating that she was suffering from multiple problems at the time. Review of the training provided to V11 by the facility did not list any training on abuse. V11 completed training on infection control, HIPAA (health insurance portability and accountability act, antimicrobial stewardship, do not abbreviate, etc. 9/4/2024 at 12:54PM, V3 LPN (licensed practical nurse) stated that she was in the building the day R2 had an incident with a staff, she just got out of the elevator and saw R2 agitated, the nurse practitioner (V11) was trying to calm R2 down, but he became more agitated. Staff moved resident to another part of the nursing station, R2 started using vulgar terms stating V11 struck him. Resident was noted with some redness to the right side of his face, he did not require any medical treatment and denied any pain. 9/4/2024 at 3:59PM, V1 (Administrator) stated that she completed the abuse investigation for R1 and R2. For R2, the conclusion was that V11 became aggressive with the resident and was escorted out of the building immediately. The facility does not provide abuse training to non-staff, V11 is not a staff of the facility but part of a provider group, the facility is not responsible for training her on abuse. 9/4/2024 at 3:41PM, V2 (DON) state that she spoke to V11 (NP) who admitted hitting the resident and was complaining of being overwhelmed. R2 is not aggressive, he is alert and oriented with some confusion. Facility abuse prevention and reporting policy revised 1/22/2019 states in guidelines that the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Under orientation and training, the document states in part that during the orientation of new employees, the facility will cover at least the following: sensitivity to resident's rights and resident's needs, what constitutes abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.

Based on interview and record review, the facility failed to implement a treatment plan for (R4) who was identified as very high risk for skin break down, admitted with an opening on the penile shaft, excoriation on the penile head/tip with the penile prosthesis in an erectile position for twenty-two days. This failure resulted in R4 sustaining a facility acquired full thickness, moisture associated skin dermatitis (MASD) measuring 8.00 centimeters (cm) x 3.00 (cm) x 0.10 (cm) (L x W x D) for one of three reviewed for wound care in a sample size of ten. Findings Include: On 7/19/24 at 12:58PM, V6 (treatment nurse) stated, MASD is caused by moisture (urine, stool, sweat and or body fluids) which would cause a break in skin due to repetitive movements or friction. R4 was admitted with a penile implant that was fixed and erect. It would not go down. We had to ensure his adult brief was in place a certain way to prevent friction. V6 stated, she was not sure what that certain way R4 adult brief was place. R4 started to have skin break down to the penis, the doctor was notified. R4 needed to have surgery to have the rod removed. V6 stated, she was not aware of what type of penile implant R4 had, how to deflate the implant, R4 did not go out on any appointment or to the hospital for the implant and was discharged before we could establish anything. On 7/19/24 at 2:45pm, V9 (ADON/assistant director of nursing) stated, R4 did not have a treatment in place upon admission for his penis. V9 stated, R4 had a photo of his penis on admission that showed an opening on the shaft and excoriation on the head/tip. V9 stated, R4 should have had a treatment put in place, the doctor should have been notified and the site should have been measured upon admission. R4 had a treatment put in place on 3/11/24. On 7/24/24 atn3:41pm, V38 (wound doctor) stated, he saw R4 once or twice. Full thickness is the third layer of skin loss. V38 stated, the facility should have been monitoring R4 for any type of skin break down. R4 needed surgery. V38 stated, he does not have any more information on R4. Hospital referral paperwork dated 2/14/2011 documents: R4 prosthesis left in the semirigid position. Nursing note dated 3/11/24 documents: R4 has a pressure injury noted to his penis. Physician order sheet date 3/11/24 document: Wound care: Penis clean with normal saline and apply zinc. Wound assessment dated [DATE] documents: R4 had a facility-acquired moisture associated skin damage. Classification: Incontinence. Stage: Full thickness. Size (cm) 8.00 x3.00 .0.10 (L x W x D). Area 24.00cm. Air loss mattress noted in place. Resident has a penile prosthesis that is fixed, erected is incontinent of bowel and bladder. Wound doctor visit dated 3/14/24 documents: wound#5. Penis is a partial thickness abrasion and had received the status of not healed. Initial wound encounter measurements are 2cm length x 2 cm width x 0.1 cm depth, with an area of 4 square cm. scant amount of sero-sanguineous. According to the national pressure injury advisory panel a stage 3 Pressure Injury is defined as a Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Pressure Injury and Skin Condition assessment dated [DATE] documents: to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented.

Based on interview and record review the facility failed to identify and treat pressure ulcers for a resident dependent on staff for care. This affected one of three residents (R4) reviewed for pressure ulcers. This failure resulted in R4's pressure ulcers not being found/treated until they were an advanced stage on 10/17/23, 3/21/24 and 4/11/24. The findings include: R4's face sheet printed on 5/24/24 shows that R4 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Acute and Chronic Respiratory Failure, Tracheostomy, Gastrostomy, Dependence on Ventilator, End Stage Renal Disease, Dependence on Renal Dialysis, and history of Sudden Cardiac Arrest. R4 was discharged from the facility on 4/29/24 to the hospital and was not in the facility on 5/24/24. R4's Shower Form dated 10/17/23 shows that R4 has skin tears to her sacrum, posterior right thigh, and right ear. A handwritten comment on this form states, open areas noted. R4's Wound assessment dated [DATE] shows that R4 developed a facility acquired Deep Tissue Injury measuring 7 x 8 x Unknown cm that was 90% deep maroon in color and 10% pink or red non-granulating tissue. (R4 was last readmitted to the facility from the hospital on 9/11/23) R4's Initial Wound Physician Progress Note dated 10/20/23 states, Wound #1 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 6 cm length x 4 cm width x 0.1 cm depth . There is a light amount of serosanguineous drainage noted which has no odor. Wound bed has no granulation, 100% slough . On 5/24/24 the facility provided two Shower Forms both dated 3/21/24. The first form shows that R4 has four open areas, sacrum, left elbow, right heel, and left heel. This form also shows that R4 has a G-tube (Gastrostomy). This form is signed by a CNA and a nurse. The second Shower Form is dated 3/21/24 and shows that R4 has an open area on her right elbow and is signed only by a nurse. R4's Wound assessment dated [DATE] shows that R4 developed a facility acquired Unstageable wound to her left elbow measuring 1 x 1.5 x Unknown cm that is described as 50% bright pink or red and 50% necrotic soft, adherent. R4's Wound Physician Progress Note dated 3/22/24 does not address R4's left elbow. R4's Wound Physician Progress Note dated 3/29/24 states, Left elbow is a stage 3 Pressure Ulcer and has received a status of Not Healed. Initial Wound encounter measurements are 1 cm length x 1 cm width x 0.1 cm depth .There is a light amount of serous drainage noted which has no odor. R4's Treatment Administration Record shows the first treatment was applied to R4's left elbow on 3/23/24. (Wound found on 3/21/24) On 5/24/24 the facility provided two Shower Forms both dated 4/11/24. The first form shows that R4 has seven open areas (none on her right lateral foot), a Tracheostomy/trach and a Gastrostomy/Gtube. This form is signed by a CNA and a nurse. The second Shower Form also dated 4/11/24 shows that R4 has only one open area on her right lateral foot This form is signed only by a nurse. R4's Wound assessment dated [DATE] shows that R4 developed a facility acquired Deep Tissue Injury measuring 2.1 x 1.8 x unknown cm. The wound is described as a 100% blood filled blister. R4's Specialty Wound Evaluation and Management Summary dated 4/22/24 shows that R4 has an Unstageable DTI (Deep Tissue Injury) measuring 1.7 x 1.5 x Not measurable cm to her right lateral foot. The wound is described as intact with purple/maroon discoloration. On 5/24/24 at 11:40 AM V17 (LPN- Wound Care Nurse) stated that R4 had 5 pressure sites at the time of her discharge. V17 stated, We do our own assessment and then we contact the wound care physician. It would be expected that the staff notify us before seeing the wound becoming a deep tissue injury. The sacral wound, the left elbow and the right lateral foot were all found during treatment of other wounds by a treatment nurse. (R4) did not move at all and she had contractures. Our skin assessments are done 2x/times a week during the showers the CNAs have the nurse come and do a skin check. R4's Care Plan Initiated on 6/30/23 states, (R4) has active skin issues and remains at high risk for further skin breakdown related to her diagnosis of anoxic brain damage, respiratory failure, End stage renal disease with dependency on dialysis, diabetes, dependency on trach and Gtube, immobility, total dependence. The interventions for this focus include Document: if skin is intact. If skin is reddened or has open areas. Report any new openings to Registered Staff.

Based on interview and record review, the facility failed to follow therapy recommendations, and fall prevention interventions to include use of a manual wheelchair and keeping the call light within reach. This affected two of three residents (R2, R3) reviewed for safe use of a motorized wheelchair and fall prevention interventions. This failure resulted in R2 using the motorized wheelchair resulting in a fall incident requiring R2 to be sent to the local hospital for treatment of a right frontal scalp hematoma. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of muscle wasting, history of falling, acute kidney failure, reduced mobility, weakness, fracture of right pubis, right artificial hip joint, osteoarthritis, and dysphagia. R2's fall report dated 1/13/24 documents: The nurse heard a loud noise in the resident's room. The nurse witnessed resident on the right side near the foot of his bed and appeared to have fallen from electric wheelchair. Under resident description: Resident stated he was attempting to move his power chair and fell . Under injury abrasion to top of scalp and laceration to left hand. Under mental status oriented to person only. Under predisposing environmental factors document equipment or device. On 1/14/23 fall root cause documents: Resident stated he was sitting up in his motorized wheelchair when he was attempting to move his chair and fell out after leaning too far. On 2/13/24 at 1:17pm, V5 (therapy director) stated when R2 was participating in therapy. R2 had a motorized wheelchair he had used in the past for mobility. At time of therapy the use of the motorized wheelchair was not attempted due to medical concern related to cognition and functional ability. R2 had poor sitting balance and required a mechanical lift for transfers which would contradict the use of a motorized scooter. R2 was utilizing a manual wheelchair during therapy. When there are any changes to a resident's assistance devices, therapy would inform the unit supervisor of the changes. R2's motorized wheelchair should have been removed by staff to ensure R2 did not use it. V5 stated the therapy department did not remove R2's chair and was unsure if it was still in R2's room after discharge from therapy. R2 should have been utilizing a manual wheelchair. On 2/15/24 at 4:00PM, V17(CNA) was the assigned aide to R2 at time of fall on 1/13/24. V17 stated she recalls R2 being in his motorized wheelchair at start of her shift in common area. A little later, R2 was on the floor in his room on the mat. V17 was unable to recall any other details of fall. V17 stated she was not sure if R2 fell from the motorized wheelchair or if the motorized wheelchair was in the room at time of fall. V17 stated she does not think she assisted R2 with going back into the bed after her shift prior to the fall. V17 does not recall anyone saying R2 could not use the motorized wheelchair. On 2/13/24 at 2:40PM, V9 assistant director of nursing (ADON/third floor supervisor) stated if there were changes in resident's assistive devices use or mobility, therapy would communicate with me or at stand-up meeting in the morning. V9 does not recall ever being told that R2 could not use the motorized wheelchair. If it was communicated that R2 could not use the device, it would be removed from the room. R2's therapy notes dated 12/16/23 documents under initial assessment wheelchair mobility: wheel fifty feet with two turns- not attempted due to medical conditions or safety concerns; type of wheelchair or scooter used - motorized; wheel one hundred fifty feet- not attempted due to medical conditions or safety concerns. Under balance: Patient sits unsupported for thirty seconds with feet flat on floor and no back support- No; amount assisted needed to sit at edge of bed- moderate assistance; time patient can sit unsupported- unable seconds. Under reason for therapy clinical impressions: Based upon examination of patient's body regions, systems and structures, patient presents with strength impairments, safety awareness deficits, balance deficits and muscle disuse and in consideration of history, personal factors and functional abilities documented in this evaluation summary. Patient requires skilled therapy. Physical therapy discharge summary dated 1/5/24 documents under wheelchair mobility patient will increase ability to safely propel in wheelchair one hundred fifty feet with supervision or touching assistance on level surfaces. At discharge required partial to moderate assistance. Under wheelchair mobility type of wheelchair manual. R2's hospital record dated 1/13/24 documents CT/computed tomography scan of head impression: no acute traumatic injury in brain or spine. No acute intracranial hemorrhage. Small right frontal scalp hematoma without underlying calvarial fracture. 41758 R3 was admitted with the diagnosis with muscle wasting and atrophy, reduce mobility, lack of coordination, abnormal posture, weakness, hemiplegia affecting left non-dominant side. Minimal data set section C (cognitive status) - brief interview for mental status dated 01/30/24 documents a score of fifteen which indicates cognitively intact. Section GG documents: 03- roll left and right - 03 indicated partial/moderate assistance- helper does less than half the effort. Helper lifts, hold or supports truck or limbs but provides less than half the effort, (functional abilities and goals/functional limitation in range of motion) documents: 1 upper/lower extremity - 1 indicates dependent- helper complete all the activities for the resident. On 2/13/24 at 1:28pm, R3 who was assessed to be alert and orient to person, place and time stated, R3 said, V13 (cna) disconnected his call light from the wall. R3 stated, he fell due to reaching for his call light. On 2/13/24 3:04pm, V11 (nurse manager) stated, R3 was reaching for something and had a fall. V11 stated we spoke with V13 about R3's call light not being answered. On 2/13/24 at 3:38pm, V12 (guest relations) stated, R3 who was alert and oriented times three, stated, he R3 fell out of bed attempting to reach the call light. R3 has never made an allegation of falling out the bed before or the inability of reaching the call light. V12 stated, if R3 stated it happened then it did. After speaking with R3, V12 stated, she completed a concern form related to V13 not having the call light within reach. Concern/Compliment form dated 1/29/24 document: V12 took the report- R3 was educated on call light use. Staff made aware resident (R3) call light is within reach when rounding. R3's care plan initiated 1/26/24 documents: R3 was at risk for fall related to deconditioning and weakness r/t left hemiplegia, lumbar stenosis, and sciatica. Interventions: Keep call light and desired personal items within reach. Fall incident dated 1/29/24 documents: Alerted to residents (R3) room, resident sitting on buttock on the floor next to bed. Resident stated, I slid out of bed while attempting to turn over. Resident assisted back to bed with mechanical lift. Mental status: oriented to person, place, and situation. Predisposing physiological factors: gait imbalance and impaired memory. No witnessed found. Fall prevention program dated 11/28/12 documents: to assure the safety of all residents in the facility. At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times.

Based on interview and record review, the facility failed to follow the physician's orders for one resident with a diagnosis of osteoarthritis by not applying a prescribed lidocaine pain patch (local anesthetic) as ordered. This affected one of three residents (R3) reviewed for pain. This failure resulted in R3 complaining and enduring left knee pain with a pain score of ten out of ten for over seven hours (zero equals no pain, five equals moderate pain, and ten equal excruciating pain). Findings Include: R3 brief interview for mental status dated 01/30/24 documents a score of fifteen which indicates cognitively intact. R3's physician order summary start date 2/8/2024 documents: Lidocaine external Patch 4% (lidocaine) -Apply to left knee and low back topically one time a day for mild pain and removed per schedule. Physician progress note dated 2/12/24 documents: R3 has a diagnosis of Osteoarthritis (OA) and left knee arthroscopy. On 2/13/24 at 1:28pm, R3 who was assessed to be alert and orient to person, time and place stated, he did not get his pain patch applied to his left knee this morning. R3 stated, his pain was a 10 out of 10. R3 stated, the pain patch did not come off because it was not applied. R3 was observed in bed while V33 (cna) and V34 (cna) provided ADL/activities of daily living care. R3 was observed without a pain patch on his left knee, no patch was observed stuck to the inside of R3's pajama or on R3's bed pad/sheets. V33 (cna) and V34 (cna) both stated, R3 did not have a pain patch on his left knee nor was the patch on R3's clothing or bed/bedding. V34 said, she provided care to R3 all day. R3 did not have a patch on his left knee this morning. On 2/13/24 3:04pm, V11 (nurse manager) stated, the nurse should have applied R3's pain patch. V11 stated, she would expect physician orders to be followed. On 2/21/24 at 2:37PM, V32 (nurse), stated, she applies R3's pain patch to his lower back and knee every time she works. The administration of R3's pain patch will be recorded on the medication administration record and on the location administration report. Location of Administration report dated 2/13/24 documents: V32 (nurse) administered, topically to back -lower, mid/ thoracic (left) Pain Management Policy dated 11/28/12 documents: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness.

Based on interview and record review, the facility failed to provide incontinence care for a resident identified as dependent on staff assistance with toileting. This affected one of three (R3) residents reviewed for incontinence care. This failure resulted in R3 not being provided incontinence care for over six hours. Findings Include: R3's minimal data set section C (cognitive pattern) dated 1/30/24 documents a score of fifteen which indicates cognitively intact. Section GG (functional abilities and goals section) documents: 01 for toileting hygiene. 01 indicates dependent- helper does ALL of the effort. Resident does none of the effort to complete the activity. Section H (Bladder and Bowel) dated 1/31/24 documents: R3 was always incontinent. On 2/13/24 at 1:28pm, R3 who was assessed to be alert and orient to person, place and time said, he was told by V13, he had to wait until the next shift to be changed one night and he did not urinate enough to be changed on a different night. R3 was unable to give exact dates. R3 said, he was left soak and wet with urine on both occasions. R3 said, he felt nasty. On 2/13/24 at 3:04pm, V11 (nurse manager) said, V13 certified nursing assistant (cna) was suspended for not providing R3's incontinence care after 1:00am on her last shift worked which was 2/9/24. V13 said, she did not make her last round. R3 was not provided incontinence care for over two hours. R3 was wet. The bowel and bladder report documents the last time R3 was provided care by V13. The morning cna provided R3's incontinence care. On 2/22/24 at 1:26pm, V1 (said) the night shift ends there shift at 7am depending on if anything extra occurs. R3's B&B/bowel & bladder- bowel continence report dated 2/9/24 at 01:04 (1:04am) documents: Incontinent by V13. R3's B&B urinary continence report dated 2/9/24 at 01:05 (1:05am) documents: Incontinent by V13. V13's disciplinary report dated 2/8/24 documents: failure to provide ADL care to R3' room/bed number. Action taken suspension. Incontinence Care policy dated 11/28/12 documents residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provide perineal and genital care after each episode.

Based on observation, interview, and record review the facility failed to perform hand hygiene before administering medications to three (R64, R79, and R146) of six residents reviewed for medication administration and before providing juice and lotion to two (R9, R20) of five residents reviewed for activities in the sample of 33. Findings include: On 1/10/24 at 8:47 AM, V6 (LPN-Licensed Practical Nurse) administered Acetaminophen ER (Extended Release) 325 mg (milligrams) 2 tablets to R64 via gastric tube. V6 did not perform hand hygiene before donning gloves to administer the medication. On 1/10/24 at 8:52 AM, V6 said I didn't use the hand sanitizer because I'm very nervous because you're following me. On 1/10/24 at 10:20 AM, V10 (LPN) administered Heparin 5000 units SQ (subcutaneous) to R146. V10 did not perform hand hygiene before administering the medication. On 1/10/24 at 10:23 AM, V10 said I didn't put on hand sanitizer, but I should have. On 1/10/24 at 10:25 AM, V8 (Activities) donned gloves and adjusted the blanket on R20. V8 then removed the gloves and did not perform hand hygiene. V8 donned new gloves and opened juice and gave it to R9. V8 changed gloves without performing hand hygiene and began to apply lotion to R20's hands. On 1/10/24 at 10:30 AM, surveyor asked V8 what she should do before and after removing gloves. V8 said I should have cleaned my hands. On 1/10/24 at 4:27 PM, V13 (LPN) performed blood pressure testing, then performed blood glucose testing for R79. V13 did not perform hand hygiene before donning gloves to do blood testing. On 1/10/24 at 4:30 PM, V13 was asked if she should have performed hand hygiene before donning gloves for blood glucose testing, V13 answered yes. On 1/11/24 at 12:00 PM, V2 (DON-Director of Nursing) said staff should always sanitize their hands before putting on and after taking off gloves. Hands should be sanitized after providing care to a resident. The facility's Infection Precaution Guidelines policy, revisions 1/10/18, documents Points to Remember: Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment. Alcohol-based hand rub may be used if hands are not visibly soiled.

Based on observation, interview, and record review the facility failed to stabilize the indwelling urinary catheter for one resident (R103) of six residents reviewed for catheters in the sample of 33. Findings include: On 1/9/24 at 9:00 AM, R103 was in her bed. R103 has an indwelling urinary catheter that is draining clear purple urine. The drainage tubing was not secured to R103's leg and moved freely. On 1/9/24 at 9:04 AM, V7 (LPN-Licensed Practical Nurse) said some facilities don't have stabilizers. V7 was asked what an alternative was. V7 said it should be taped. On 1/10/24 at 12:55 PM, V2 (DON-Director of Nursing) said all catheters should have a securement device on the resident. The Wound Rounds report for R103 dated 1/11/24 indicate a Stage 4 pressure wound on the sacrum. The Order Summary Report indicates diagnosis for indwelling catheter contamination of Stage III or IV Pressure Ulcer dated 10/27/2023. The Order Summary Report indicates secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction. The facility's Urinary Catheter Care policy, revision 2/14/19, documents 5. Indwelling catheters may be secured to prevent trauma and tension.

Based on observations, interviews, and records reviewed, the facility failed to implement effective fall prevention interventions and determine the root cause of previous falls to prevent and/or reduce the risk of residents falling. This affected three of three residents (R6, R4, and R8) reviewed for fall prevention interventions. This failure resulted in R6 falling from bed while staff was providing direct care and leaving resident unmonitored returning to find R6 on the floor. R6 was sent to the hospital assessed to have sustained a bilateral subarachnoid hemorrhage. The findings include: 1.R6 is [AGE] years old with diagnoses including but not limited to End Stage Renal Dialysis, Weakness, Diabetes, Epilepsy, Encounter for Palliative Care. R6 cognitive assessment dated [DATE] indicates a score of 11 and no behaviors were reported. On 12/20/23 at 9:45AM V11, Certified Nursing Assistant (CNA), said on 10/11/23 I was giving R6 a bed bath. V11 said I left the room to get a pillowcase and sheet. V11 said when I returned to the room R6 was on the floor. V11 said during her bath R6 was a little agitated. V11 said R6 had a history of throwing her legs out the bed. V11 said I saw R6 kick her leg out before I left the room and I put it back in the bed. V11 said when R6 was on the floor she was on her right side, in between the two beds. V11 said later I was told by other staff that R6 has a behavior of throwing herself out of bed. V11 said R6 was not on a floor mat, the mat was on the other side of the bed. V11 said R6 did not land on the mat. V11 said R6 had a knot developing on her head after the fall. V11 said I had never seen R6 stand up, R6 required total care and she was not able to stand up. V11 said R6 had to roll out, if she kicked her leg out. On 12/20/23 at 12:27PM V17 said the Restorative Observation is done to get an understanding of what kind of Activity of Daily Living care the resident needs. V17 said the Restorative Observation can be used to develop the care plan. V17 said a resident's bed mobility ability can change. V17 said the staff will know how to provide care for a resident by the preceding staff communicating with the oncoming staff. V17 said R6's care plan should include her need for assistance with bed mobility. The surveyor and V17 reviewed R6's care plan. V17 said bed mobility is not on there. V17 said any information on the care plan designated with the letter K will carry to the CNA Kardex and the CNA can see the resident care needs. On 12/20/23 at 2:10PM V21, MDS Nurse, said it is important to know a resident's functional status. V21 said it is important for staff to know how much assistance is required for a functional task. V21 was asked if as nurses we still consider Bed Mobility an activity of daily living, V21 replied, yes. On 12/20/23 at 2:49PM V3, Director of Nursing, said if a resident falls and suffers a head injury then floor mats were not an effective intervention for that person. On 12/21/23 at 10:17PM V24, Doctor, said a subarachnoid hemorrhage can be caused by trauma. V24 said R6's subarachnoid hemorrhage was likely caused by trauma. R6's Restorative Observation dated 9/12/23 documents observation of bed mobility is total dependency with two plus person's physical assist. R6 believes she is capable of increasing independence. R6's Fall Scale dated 9/12/23 indicates a score of 16, low risk. R6's fall scale dated 10/1/23 indicates a score of 31, moderate risk. Risk factors include diagnosis and R6 overestimates or forgets limits. R6's Functional Status dated 9/29/23 documents the use of one person with total dependency for bed mobility. Range of Motion Limitations include impairments to upper and lower extremities on both sides. R6's incident report dated 10/1/23 documents R6 on the floor. No cause of R6's fall was documented or provided. A summary of R6's 10/1/23 fall was provided documenting her diagnosis, orientations, and that R6 was unable to say what happened. Bed position and ability to move her own extremity is documented. No cause or circumstance causing or related to the fall was provided. R6's incident report dated 10/11/23 documents R6 on the floor with hematoma noted to the right forehead. Incident report submitted to The State Agency does not include why or cause to R6's fall. Statements in investigation include V19, Registered Nurse. Attempts to contact V19 during the survey were unsuccessful and V19 is no longer employed at the facility. V11, CNA, statement says she did not witness the fall. Care plan reviewed for R6 no bed mobility assistance listed despite self-care deficit related to hemiplegia and limited mobility. R6's hospital record CT Head dated 10/11/23 Final Result Impression: Scattered bilateral subarachnoid hemorrhages most prominent along the right MCA cistern and the right Sylvian Fissure. Subarachnoid hemorrhages (pleural) along the high left parietal lobe and posterior right temporal region also noted. Emergency Department Course notes R6 admit for further monitoring and possible hospice transition. 2. R4 is [AGE] years old with diagnoses including, but not limited to Cerebral Palsy, Atrial Fibrillation, Vascular Dementia, Autistic Disorder, Schizophrenia, Bipolar Disorder, Generalized Anxiety, and Schizoaffective. Cognitive assessment dated [DATE] indicates a score of 13. On 12/15/23 at 1:10PM V10, Licensed Practical Nurse (LPN), said on 11/12/23 I stepped into R4's room and she was sitting on the floor. V10 said this is a behavior for R4. V10 said I have never seen R4 actually put herself on the floor, but I am told this is a behavior for her. On 12/15/23 at 2:14PM V9, LPN, said R4 throws herself out of the wheelchair or bed onto the floor. On 12/19/23 at 10:48AM V2, Certified Nursing Assistant (CNA), said when things don't go R4's way, she puts herself on the floor. On 12/19/23 at 2:19PM the surveyor looked inside R4's room. R4 was not in the room and no floor mats were observed on the floor, along the walls, or inside the room. On 12/20/23 at 8:56AM the surveyor observed R4 in her bed, the bed was positioned higher than the roommate's bed, and one floor mat was observed placed between R4's bed and the roommate's bed. R4's bed is not up against a wall or surface in which a floor mat cannot be placed. V18, CNA, walked into R4's room and said she is the assigned CNA for the room. V18 showed the surveyor R4's wheelchair and lifted the seat/cushion. No skid pad was observed on the wheelchair seat. V18 said there is 1 floor mat in the room for R4's roommate, R12. R12 quickly said that's for her (indicated R4). V18 demonstrated R4's bed lowers more, nearly to the floor. V18 said no one reported to me that R4 has behaviors. V18 was asked what safety interventions are in place for R4. V18 said she could check the computer. V18 was unable to find the information and asked V22, Assistant Director of Nursing, who then called V17, Restorative Nurse, who assisted. V17 had to click multiple sites in R4's electronic record before the information for bilateral floor mats and nonskid pad were located for R4. The surveyor asked V18 if she was aware that R4 required bilateral floor mats and a nonskid pad in her wheelchair. V18 said not until now. V18 said she would not have known where to locate the nonskid pad for R4. V17 entered R4's room with the surveyor and observed only 1 floor mat, not bilateral mats for R4. V17 said someone must have taken the other mat out of the room. V17 said the restorative office has nonskid pads available for the residents. V17 said staff may have removed the nonskid pad prior if it was soiled when the surveyor reported it had not been present when V18 checked with the surveyor. R4's care plan documents she is alert and oriented times two with periods of confusion. R4 has behaviors of throwing herself on the floor and intentionally slides out of her wheelchair. R4 has floor mats (pleural), nonskid device on wheelchair and keep floor mats in place while resident in bed. 3.R8 is [AGE] years old with diagnosis including but not limited to Dementia, Repeated Falls, Hypertension, Difficulty in Walking, Transient Ischemic Attack and Cerebral Infarction. On 12/19/23 from 11:25AM thru 11:42AM R8 was observed sitting in her wheelchair. R8 was moved throughout the unit during the time from the nurses' station to the dining room with staff assistance. R8 observed to be wearing pink fuzzy socks and no shoes or slippers and the socks had no nonskid on them. R8 is documented on the Fall Incidents list with falls on 10/21/23; 10/30/23; 11/3/23 and 12/5/23. R8's incident report dated 10/21/23at 9:16PM states R8 seen on the floor and R8 stated I am trying to get out of the bed, and I fell . The fall care plan intervention states R8 should be up in wheelchair in a supervised area when awake at night. No follow up notes related to the fall investigation was provided to the surveyor. There is no documented cause of R8's fall. R8's incident report dated 10/30/23 at 9:16PM (same time as prior fall) states R8 observed sitting on the floor next to her bed. There are no follow up notes related to the fall investigation was provided to the surveyor. There is no documented cause of R8's fall. There is no added intervention to the fall care plan. R8 fell on [DATE], 3 days after her last fall. R8's care plan dated 5/16/23 for functional deficit in ambulation states ensure R8 is wearing proper footwear. On 12/19/23 the surveyor requested the documented Root Cause Analysis or investigations that show the fall root cause for R4 and R6 from V4, Administrator. V4 said V3 is the fall nurse. On 12/20/23 before interview with V4 at 10:15AM, the surveyor requested the information for the root causes analysis for R4 and R6 falls. By the end of day on 12/20/23 no root cause analysis documentation or investigations were provided to the surveyor. On 12/20/23 at 1:44PM V3, Director of Nursing, said I have been in this position since last Monday or Tuesday (12/11/23 or 12/12/23.) V3 said I have not been told I am the fall coordinator. V3 said the purpose of a root cause analysis is to find a way to prevent another fall and to develop interventions. V3 said I am not in charge of falls. The facility Fall Prevention Program dated 11/21/17 states the program includes the following: immediate change in interventions that were successful. The care plan incorporates addresses each fall. Falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safe interventions. Interventions include direct care staff will be oriented and trained in the fall program. Footwear will be monitored to ensure the resident has proper fitting shoes or nonskid footwear.

Based on interview and record review, the facility failed to prevent or determine how an injury of unknown origin to the left femur for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining an injury to the left femur with the bone exposed through the left thigh wound causing the resident to be sent to the local hospital for treatment. Findings Include: R1 is a [AGE] year-old with the following diagnoses: functional quadriplegia and osteomyelitis of the sacral region. R1 was admitted to the facility on [DATE]. A Nursing note dated 11/7/23 documents the floor nurse (V8) was informed by the wound care nurse (V4) that R1's left thigh wound was bleeding. Upon observation, R1 was awake and in no distress. Bleeding was observed to the left thigh wound. The wound care nurse applied pressure to the site. While the nurse was reviewing R1's chart at the nurse's station, the DON informed the nurse that R1 needed to go out to the hospital via 911 due the wound bleeding and bone protrusion. The paramedics arrived in the facility and transferred R1 to the hospital. A Wound Care note dated 11/7/23 documents while doing R1's daily treatments to the left ischium and sacral wounds, R1 was repositioned on R1's back. At this time, the wound tech (V9) and the wound care nurse (V4) noticed blood along with a blood clot on R1's pad. Blood was coming from the left thigh wound. Another wound care nurse (V10) was called from another room to help assess R1. The floor nurse (V8) was notified, and pressure was applied to the wound with gauze and an ABD pad. The DON was notified. When the wound care nurse removed the gauze, bone was protruding from R1's thigh. 911 was called. The wound was covered with a dressing until the paramedics arrived and took over. The Fire Department Record dated 11/7/23 documents the crew was dispatched to the facility for a medical emergency. According to the wound care nurses on scene, R1's left femur is broken, and the bone is protruding out of the leg. The wound care nurse also mentioned R1's wound is an old wound, but the break in the femur is new. R1's leg was already wrapped up and cleansed prior to arrival. The wound care nurse also stated the old bandages were filled with blood. R1 was found alert and oriented times one in bed. A deformity was noted to the left upper leg. R1 was given 50 micrograms of fentanyl pain medication through an IV while in route. R1's level of distress is documented as moderate. R1 was transferred to the hospital without incident. The Hospital Records dated 11/7/23 documents orthopedic surgery was consulted for a broken femur on R1. The orthopedic surgery note documents staff at the nursing home was treating R1 for chronic appearing wounds on the left side. While the dressing change was performed today, they noted that bone was protruding from the wound on the left thigh. There was no known history of trauma. There is an obvious type three open left femur fracture with a chronic appearing wound. The left lower extremity has an obvious deformity. There is a large, open, chronic appearing wound measuring approximately 10 cm across its greatest diameter to the anterior medial, mid-thigh with protruding proximal femoral bone. There was slow losing blood from the wound. Given the history of the appearance of the wound, it is likely that the femur fracture is chronic, and the flexion deformity of the proximal fragment has been gradually degrading the skin with full thickness perforation through the skin earlier today at the nursing home. Reduction attempts were unsuccessful in the emergency department for realigning the femur. This is likely contributed due to the chronicity of the injury. X-ray of the femur was completed on this day and shows there is an oblique fracture through the junction of the middle third of the femur. Bone fragments are completely displaced an overriding. There is no identifiable destructive bone lesion to indicate pathological fracture. The Facility Serious Injury Incident and Communicable Disease Report dated 11/8/23 documents R1 is alert and oriented times zero and nonverbal with a history of multiple wounds. During wound care, R1 was noted with bleeding to the left leg wound site. Upon further assessment, nurses noted visible bone at the wound site. The wound was wrapped to control bleeding. R1 had no visual cues of pain or distress. 911 was called. On 11/9/23 at 10:19AM, V2 (Paramedic) stated the paramedics were called to the facility due to R1 having a bone sticking out of a wound on the left leg and the wound was bleeding. V2 endorsed facility staff was not able to say how the fracture occurred and R1 was not able to say what happened either since R1 was nonverbal. V2 reported a wound care nurse told V2 they were doing the dressing changes and when R1 was turned back on the bed the bone came out of R1's leg. V2 stated the femur is the strongest bone in the body and open fractures like the one R1 had happen from high impact. On 11/9/23 at 12:06PM, V3 (CNA) stated V3 changed R1 around 11AM and there was no bleeding noted at that time. V3 endorsed R1 is nonverbal, has contracted legs, and can't move independently. On 11/9/23 at 12:17PM, V4 (Wound Care Nurse) stated V4 was changing the wound dressings on R1's back side and had R1 rolled on R1's right side. When the wound tech rolled R1 on to R1's back to be turned to the other side, blood was noticed on the pad underneath R1 with a blood clot. V4 endorsed getting V10 (Wound Care Nurse) to help with the situation. V4 and V10 notified appropriate staff and applied pressure to the wound. V4 endorsed since R1 was actively bleeding then 911 was called for R1 to be evaluated at the hospital. V4 stated before the paramedics arrived V4 was cleaning the wound and noticed bone was sticking out of the wound once all the gauze was removed. V4 stated it was about an inch of bone sticking out of the leg. V4 denied noticing a deformity to R1's left leg. V4 reported R1 is nonverbal, and no one knows how the fracture occurred. On 11/9/23 at 12:42PM, V9 (Wound Care Tech) stated V9 was assisting V4 change R1's dressing and rolled R1 to the side while V4 changed the wounds on the back. V9 endorsed when R1 was rolled onto the back to go to the other side, they noticed blood was on the pad underneath R1 and blood was found coming from the left thigh wound. V9 stated bone was found sticking out of the left thigh wound about one or two inches while V4 was cleaning the wound. V9 denied being aware how R1 fractured the left leg. V9 stated R1 is nonverbal at baseline and not able to say how the fracture occurred. V9 denied knowing what an injury of unknown origin is. On 11/9/23 at 12:55PM, V10 (Wound Care Nurse) stated V10 was called to R1's room by V4. V10 endorsed R1 was bleeding from the left thigh wound and when staff was cleaning the wound, a piece of bone was sticking out of the wound about one inch long. V10 reported this would be considered an injury of unknown origin because R1 is not able to say what happened and neither can staff. On 11/9/23 at 1:31PM, V8 (Nurse) stated R1 was getting wound treatment completed by V4 when V8 was notified that R1 was bleeding from the left thigh wound. V8 reported V4 or V10 saw bone coming out of R1's leg so 911 was called to take R1 to the hospital. V8 defined an injury of unknown origin as when people can't talk to tell you what happened and no one else knows what happened. Based on this definition from V8, V8 was not able to say if R1's injury would be considered an injury of unknown origin. On 11/9/23 at 3:27PM, V1 (DON) stated V1 was notified R1 was bleeding from the left leg wound and told V4 to send R1 to the hospital for active bleeding. V1 endorsed when staff was cleaning the wound before the paramedics arrived, they noticed a white piece sticking out of the wound. V1 reported V4 and V10 thought it was a piece of gauze but realized it was bone when they tried to take it out. V1 stated this is an injury of unknown origin because R1 was not able to say how the fracture occurred and staff is not sure how the fracture occurred. On 11/14/23 at 10:39AM, V12 (Hospital Orthopedic Surgeon) stated R1 had an open fracture to the middle of the left femur. V12 endorsed this fracture is chronic meaning it is between three to six weeks old. V12 reported the wound to the left thigh is due to the bone causing pressure to the skin breaking it open. V12 stated this fracture is a type III fracture which means the wound caused by the exposed bone is larger than 10 centimeters. V12 stated there is an obvious deformity to the left thigh meaning the thigh looked like it was on an angle. V12 endorsed nursing staff should have noticed the deformity to the left before the bone came through the skin. V12 denied this being a pathological fracture, from osteomyelitis, or being caused by R1's leg contractures. V12 stated this kind of fracture is due to some kind of impact to the bone. The last hospitalization for R1 was on 8/4/23. The Hospital Records dated 8/4/23 document R1 was admitted to the hospital for a sacral ulcer infection. There is no deformity of the left leg documented on this hospitalization . The Restorative Contracture Observation date of 10/5/23 documents R1 has limitation and range of motion. R1 has moderate contractures of the left hip and knee. R1 is bedbound, paralyzed, and unable to initiate movement independently. The Minimum Data Set (MDS) dated [DATE] documents R1 does not have a score for the Brief Interview for Mental Status due to R1 rarely/never being understood. Section GG of the MDS documents R1 is dependent in all care areas. R1 is not able to attempt any bed mobility or transfers. Section I of the MDS documents R1 does not have any fractures and does not have any bone diseases other than osteomyelitis of the sacral region. The care plan was reviewed and there is no documentation regarding R1 having weak bones or any bone diseases that would easily cause a fracture. The policy titled, Abuse Prevention and Reporting- Illinois, dated 10/24/22 documents, .Injuries of Unknown Source: . and injury should be classified as an injury of unknown source, when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury, could not be explained by the resident; and the injury is suspicious, because of the extent of the injury or the location of the injury (e.g., the injury is located in an area, not generally vulnerable to trauma) or the number of injuries, observed at one particular point in time or the incidence of injuries overtime.

Based on interview and record review, the facility failed to order and provide wound care treatments for a left thigh wound for nine days after the wound was discovered for one (R1) out the three residents reviewed for wound care treatments in a total sample of three. This failure resulted in the left thigh wound increasing in size from 6.5cm x 5.5cm x 4cm to 9cm x 4cm x 4cm within seven days. Findings Include: R1 is a [AGE] year-old with the following diagnoses: functional quadriplegia and osteomyelitis of the sacral region. R1 was admitted to the facility on [DATE]. The Wound Assessment Details Report dated 10/16/23 documents the left front thigh wound was identified on this day. It is documented as unstageable. The wound measures 6.5 cm x 5.5 cm by unknown. There is no documentation of what kind of dressing was applied to the wound. The Wound Assessment Details report dated 10/24/23 documents the left front thigh wound is still unstageable and measures 6 cm x 5 cm x 4 cm. There is no documentation of what kind of dressing was applied to the wound. The Wound Assessment Details Report dated 10/31/23 documents the left front thigh wound is still unstageable and has declined. The wound is now 9 cm x 4 cm x 4 cm. The Wound Nurse Practitioner note dated 10/19/23 documents R1 developed a new pressure injury to the left thigh region. It is unstageable and measure 7cm x 5cm x 0.4cm with a moderate amount of serosanguineous drainage. This wound is documented as needing to be cleansed with normal saline with silver alginate applied and a border gauze to cover the wound. No order was put in the TAR for this wound on this date. The Wound Nurse Practitioner note dated 11/2/23 documents the left thigh wound is an unstageable pressure injury that measures 9 cm x 4 cm x 4 cm. The wound has declined by getting larger in size. The wound has a moderate amount of serosanguinous drainage with a mild odor. The wound bed has 90% bright red granulation tissue with 10% slough. On 11/9/23 at 12:17PM, V4 (Wound Care Nurse) stated the wound to the left thigh is a stage four pressure ulcer because it is down to the bone. V4 was unsure of the exact date but reported the wound developed about one month ago. V4 stated the left thigh wound has deteriorated by getting larger in size and having more slough tissue. On 11/9/23 at 2:51PM, V11 (Wound Nurse Practitioner) stated the first order placed for the left thigh wound was silver alginate and to be covered by a dressing after cleansing. V11 endorsed silver alginate is used as an antimicrobial agent and helps with absorption of drainage. V11 reported seeing R1 on 10/26/23 and changing the treatment order to Dakin's solution which is a stronger antimicrobial treatment. V1 endorsed changing the wound treatment to this because the wound was larger in size, had a mild odor, and had more slough tissue. V11 endorsed while completing rounds a wound care nurse from the facility rounds with V11 and enters the orders into the computer system after V11 verbally tells the nurse the order. V11 stated if a dressing is not completed on an open wound, then the wound can have a decline, or an infection can develop. On 11/9/23 at 3:05PM, V10 (Wound Care Nurse) stated V11 comes around weekly to round on the residents and put in any new orders as they are rounding together. V10 reported all orders made by V11 should be put in the computer otherwise staff will not know what treatments to complete. V10 endorsed if no treatments are completed on a wound then the wound can become worse or infected. V10 stated R1's left thigh wound did get worse by getting larger in size. V10 endorsed if an order is not in the computer system, then the physician should be contacted as soon as possible for an order. On 11/9/23 at 3:27PM, V1 (DON) stated a wound nurse rounds with V11 while V11 is in the building and enters in the new wound treatment orders. V1 endorsed the new orders should be put in the system immediately. V1 stated wound care dressings are not done as ordered then a wound could deteriorate. V1 endorsed if V11 verbalized the order then it should be put into the computer system where it is generated in the Treatment Administration Record/TAR so staff know how to treat the wound. When asked what does it mean if there is no documentation for wound care treatments being completed, V1 stated, If it's not charted, then it is considered not done. That's not our policy. That's a nursing policy. The Physician Order Sheet documents wound care treatment orders for the left thigh wound were placed on 10/25/23. There are no documented orders for wound care treatments for the left thigh site before this date. The Treatment Administration Record dated 10/2023 documents the first treatment for the left thigh wound was completed on 10/25/23 on the day the treatment was ordered. There are no other completed treatments documented on this wound site before 10/25/23. The Care Plan dated 10/26/23 documents R1 has active skin issues and remains at high risk for further skin breakdown related to immobility, incontinence, total assist in care status, and osteomyelitis. One of the interventions for this care plan is documented to apply treatments as ordered. The policy titled, Pressure Injury and Skin Condition Assessment, dated 1/17/18 documents, 18. Physician order treatments shall be initialed by the staff on the electronic treatment administration record after each administration. Other nursing measures not involving medication shall be documented in the weekly wound assessment or nurse's notes. The policy titled, Physician Orders- Entering and Processing, dated 1/31/18 documents, Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders .5. Following a physician visit, a licensed nurse will check for any orders that require confirmation on your clinical> orders> pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed. 6. Verbal and telephone orders will be documented as such in the electronic medical record.

Based on interview and record review, the facility failed to properly insert a urinary catheter and inflated the catheter balloon in the resident's (R1) urethra during the insertion for one out of three residents reviewed for catheter care in a total sample of six. This failure caused R1 to be hospitalized for a traumatic urinary catheter insertion where blood collected in the urinary catheter bag, a urinary tract infection, and urinary retention. Findings Include: R1 is a [AGE] year-old with the following diagnosis: diffuse traumatic brain injury, encounter for tracheostomy and gastrostomy, and neuromuscular dysfunction of the bladder. R1 admitted to the facility on [DATE] and discharged on [DATE]. R1's EMR- Medication Administration note dated 9/22/23 documents a new urinary catheter was reinserted due to leakage of the old urinary catheter. 100 ML of clear urine was noted. R1's Nursing note dated 9/23/23 at 1:44 PM documents R1 complained of pain from getting a urinary catheter reinserted yesterday. Blood was coming from the genital area. R1's Nursing note dated 9/23/23 at 3:32 PM documents R1 had a heart rate of 165 bpm and stomach was distended. There was no urine return into the urinary catheter bag. A new urinary catheter was reinserted, but still no urine collected into the bag. The Hospital Records dated 9/23/23 document R1 was sent to the hospital with tachycardia and appeared to be septic. R1 was initially hypotensive with blood pressures in the 80s but responded well to fluids. R1 was found to have a urinary tract infection and needed to be sent to the intensive care unit due to not being able to maintain blood pressure. A CT (computerized tomography) scan of the R1's abdomen was requested because of apparent distention. The CT of the abdomen and pelvis was completed on 9/24/23 at 1:36 AM and showed the urinary catheter balloon was located in R1's penile urethra. The Laboratory Levels dated 9/23/23 at 4:06 PM document the blood urea nitrogen level as 57 mg/dL (normal is 5-28 mg/dL) and creatinine as 1.3 mg/dL (normal is 0.74-1.2 mg/dL). R1 had a diagnosis of acute kidney injury in the intensive care unit likely to pre-and postrenal in the setting of shock and obstructive uropathy. There was a traumatic urinary catheter insertion at the nursing home. Urology was consulted. A Urology note dated 9/24/23 at 6:51 AM documents R1 had urinary retention with urethral trauma. The urinary catheter was found to be in the urethra. Hospital nursing staff was unable to successfully replace the urinary catheter. The urologist was called to insert a different type of urinary catheter. With some effort, the urinary catheter was able to be placed. 1100 mL of urine drained immediately upon the new catheter being placed. On 10/5/23 at 1:45PM, R1 stated the urinary catheter started leaking the day before going to the hospital so a new one was placed but after that I had pain in the catheter area that I did not have before. R1 endorsed the next day the catheter started bleeding and was more painful. R1 endorsed being sent to the hospital the next day due to not being able to urinate and the urinary catheter only collecting blood. R1 endorsed having a procedure done while at the hospital so a new catheter could be put in. On 10/5/23 at 1:00PM, V3 (Nurse) stated the CNA notified V3 there was bright red blood in R1's urinary catheter bag. V3 endorsed taking that catheter out and putting in a new catheter. V3 reported putting a new catheter in place but state no urine would collect in the bag. V3 stated irrigating the catheter but only got bright red blood back for return. V3 stated R1's stomach looked bigger also. On 10/5/23 at 2:56 PM, V7 (CNA) stated the day before going to the hospital V9 replaced R1's urinary catheter due to leaking. V7 denied emptying any urine from the bag before leaving for the day but endorsed it was inserted an hour before V7 left. V7 reported staff check for bleeding after a urinary catheter insertion to monitor the resident. On 10/5/23 at 3:33pm, V2 (DON) stated R1 had a difficult urinary catheter insertion and blood was in the catheter tubing. V2 reported the nurse practitioner was notified and sent R1 out to the hospital for an evaluation. V2 endorsed staff need to monitor for urinary output, a distended stomach, bleeding, and pain after a urinary catheter insertion. V2 reported if there is no urine collecting in the bag within 4-6 hours then there is an issue with the catheter. On 10/5/23 at 3:48PM, V8 (CNA) stated R1 was having problems with a leaking catheter so V3 changed the catheter but when V8 returned to the room after lunch the tubing was filled with blood during repositioning. V8 reported emptying about 500 mL of only blood from the bag. V8 reported blood was also coming from R1's genital area. On 10/5/23 at 4:02PM, V9 (Nurse) stated V9 changed the urinary catheter on 9/22/23 due to R1 having urine leak from R1's genital area. V9 stated, You insert the tube until you feel like you're far enough back. After that you insert the water to inflate the balloon. V9 stated you want to make sure that you have at least a little bit of yellow urine in the tube coming out to make sure that you're actually in the bladder. V9 reported urinary output and bleeding need to be monitored after insertion. V9 stated, You get everything set up and then you clean the head of the p****. You insert the tube until you feel like you're far enough back. After that you insert the water to inflate the balloon. Do you want to make sure that you have at least a little bit of yellow urine in the tube coming out to make sure that you're actually in the bladder. On 10/5/23 at 4:38PM, V10 (Nurse) stated V10 was not made aware R1 had a new urinary catheter but should have been told so it could have been monitored more closely. On 10/6/23 at 3:14PM, V12 (Nurse Practitioner stated nursing staff notified V12 about the amount of blood in R1's urinary catheter bag. V12 reported when assessing R1 after the catheter was attempted to be put in a second time only blood was coming out of the tubing even after irrigation. V12 endorsed urinary output should be monitored after place a new catheter to make sure the kidneys are functioning properly. V12 endorsed a physician should be notified for a difficult catheter insertion in case the resident needs to be sent out to the urologist. On 10/6/23 at 3:49PM, V13 (Primary Physician) stated the only thing that needs to be monitored after a urinary catheter insertion is that urine is collecting. V13 reported urine needs to be collecting at a minimum of 15 mL an hour to be considered normal kidney function. V13 endorsed people should make one to two liters of urine a day. V13 denied being aware of any difficulties putting in the catheter and reported a physician should be notified of difficult insertion to assist with placement. V13 stated inflating a urinary catheter balloon inside the urethra can cause direct trauma from the amount of pressure. R1's Care Plan dated 4/10/23 documents R1 has the following conditions requiring continued use of an indwelling catheter: stage four pressure ulcer with urine impeding healing. Interventions include assess for complication of catheter, position tubing to facilitate flow, observe for signs and symptoms of urinary tract infection, and notify the physician of any changes. R1's Physician Order Summary documents there was an order placed on 4/14/23 to change the indwelling urinary catheter for leakage, blockage, or accidental removal. The urinary catheter should be monitored every shift. An order on 6/19/23 documents every shift should record the total output of the urinary catheter. R1's Medication Administration Record dated 09/2023 documents an indwelling urinary catheter was changed on 09/22/23 at 3:30 PM. The output for the urinary catheter on 09/22/23 is documented three times a day. The dayshift is documented as an output of zero mL, there is no documentation for the evening shift, and there is an output of 550 mL for the night shift. The output for the urinary catheter on 09/23/23 is documented one time before R1 went to the hospital on the dayshift as zero mL. The Laboratory Report dated 7/28/23 documents the blood urea nitrogen level and creatinine level are within normal limits. There is no documentation that R1 had any issues with kidney function while at the facility. A policy on urinary catheter insertion and urinary catheter care/monitoring requested during this investigation. Per V1 (Administrator), the facility does not have any policies on urinary catheter insertion or care.

Based on observations, interviews, and records reviewed the facility failed to develop and implement a plan of care with interventions to reduce and/or prevent the risk of falling to include supervision and monitoring. This affected four of four residents (R1, R10, R19, and R20) reviewed for fall prevention interventions. This failure resulted in R1 not being supervised or monitored by staff resulting in a fall incident sustaining an acute fracture of the anterior and posterior wall of the left frontal sinus, and R10 being left unassisted by facility staff resulting in a fall incident sustaining a right femoral neck fracture. Findings include: 1.R1 is [AGE] years old with diagnosis including but not limited to Skull and Facial Bones Fracture, Traumatic Subdural and Subarachnoid Hemorrhage, History of Falling, Alcoholic Cirrhosis of Liver, and Psychoactive Substance Dependence. R1's cognitive patterns assessment dated [DATE] identifies him with a score of 12, moderately impaired. R1's fall scale evaluation dated 4/30/23 identifies him as a high risk for falling. a. Incident report for R1 dated 5/11/23 states nurse heard a noise and found R1 on the floor bleeding from his head. Nurse witness statement reads she was passing medications when she heard a loud noise. Per record R1 was hospitalized from 5/11/23 until 5/17/23. Hospital records dated 5/11/23 note CT of the head findings Left Frontal Scalp, Forehead and Left Periorbital Hematoma. Acute Fractures of The Anterior and Posterior Wall of The Left Frontal Sinus. b. On 7/26/23 at 12:26PM V21, Certified Nursing Assistant (CNA), said on 5/21/23 R1 kept getting up from his bed, he was trying to walk. V21 said R1 was put at the nurses' station and then he fell . V21 said she and the nurse heard a sound and then R1 was on the floor. V21 said I was at the nurses' station. V21 said I would have to walk across the nurses' station to get to R1 to prevent him from falling. V21 said I think the nurse was at a medication cart. V21 said neither I or the nurse were next to R1. On 7/26/23 at 1:33PM V24, Registered Nurse (RN), said on 5/21/23 R1 had been in bed and then he became restless. V24 said the CNA brought R1 to the nurses' station, he was sitting in front of the nurses' station, and then all of a sudden he fell forward. V24 said she did not see R1 fall but heard the sound. V24 said staff was sitting at the desk. V24 said no one was assigned to watch R1 at that time. V24 said the intervention to bring him to the nurses' station was not effective that night to prevent a fall. V24 said R1 sustained a laceration. R1's progress notes dated 5/21/23 at 1:58AM state he became restless and got out of bed. He was sitting at the nurses' station when he fell out of the chair. Laceration observed to right side of head with bleeding. R1's incident report dated 5/21/23 states R1 fell before staff could intervene. R1 hit his head. V21's witness statement states R1 was unsteady and trying to get up. R1 brought to nurses' station for closer monitoring. Heard a noise resident had fallen. V24's witness statement states R1 to be more closely monitored at the nurses' station. Statement reads V24 said she heard a noise and V24 observed R1 on his stomach. Per records R1 was hospitalized from 5/21/23 and readmitted on [DATE]. c. R1's incident report dated 5/27/23 states resident on floor. Witness statement of V38, CNA, states on 5/27/23 R1 was sitting in a wheelchair across from the nurses station while she was charting and heard a loud noise. R1 was on the floor. V37, LPN, witness statement states on 5/27/23 V37 was off the floor when R1 fell . R1's record indicated he was hospitalized on [DATE] and readmitted on [DATE]. d.R1's incident report dated 6/3/23 notes R1 on mats next to bed on buttocks. R1 sent to the hospital and readmitted on [DATE]. R1's records indicate he was hospitalized on [DATE] and readmitted to the facility on [DATE]. R1's progress notes dated 6/30/23 states R1 has poor safety awareness and declining. R1 impulsive to ambulate/transfer unassisted and R1 not realizing he needs assistance. When out of bed kept in common area within view. On 7/26/23 at 2:34PM V13, Director of Nursing, said R1 fell on [DATE]. V13 said the nurse reported R1 was trying to get to the bathroom. V13 said the root cause of R1's fall was he was attempting to walk unassisted with a history of Ataxic Gait. V13 said after a therapy re-evaluation they said R1 should not be walking unassisted. V13 said the root cause of R1's fall on 5/21/23 was that he fell asleep in his chair and leaned forward. V13 said he nurse, and CNA were assigned to more closely monitor him. V13 said R1 is a high fall risk and needs to be monitored despite fall precautions used. V13 said R1 is unable to be redirected. V13 said we want R1 in an area where staff can see him at all times and the goal is to intervene. V13 said when R1 fell at the nurses' station he was sitting outside the station, not inside. V13 said since the fall on 5/11/23 R1 was not placed inside the nurses' station. Following his fall on 5/21/23 R1 sustained a laceration requiring 2 or 3 sutures. V13 said if you are not looking at the resident, then you are not monitoring. V13 said R1 had another fall on 5/27/23 and the reclining chair was not in place at that time, we didn't have a chance to put the chair in place. e. R1's progress notes dated 7/26/23 state he slid out of his chair at the nurses' station. On 7/26/23 at 4:12 PM the surveyor watched surveillance camera footage from 12:00PM - 1:33PM. V12, Administrator and V13 in the room. Footage started with resident sitting in reclining chair behind nurses' station, helmet on, legs under desk writing area. Staff at his side initially. Meal tray served to R1. At 1:07PM the staff observed feeding R1. At 1:16PM R1 feeding self, sitting alone at desk, no staff at the station near him. V12 said the person at desk with back to R1 is a third-party Nurse Practitioner (NP). Surveyor observed the NP is not able to see R1 with her back towards him. R1 noted to lean forward 30 to 45 degrees while sitting in the chair. At 1:22PM observed R1 sitting alone no staff looking at him. R1 pushed self-back from desk. Chair in upright position. R1 stood up, chair rolled approximately 2 feet back from him (per view on footage), R1 lost balance, fell back onto floor and onto his buttocks, and his helmet came off. Nurse from cart, outside of station assisted R1 back into chair. V13 said for R1's safety he is at the nurses' station so staff can monitor him. The current interventions are as effective as they can be. He has a tendency to lean forward, and he has a brain tumor. The surveyor asked V13 if the interventions are effective to prevent R1 from falling. V13 said we are doing as much as we can. R1's care plan initiated on 5/18/23 for safety denotes outcome to be R1 will remain safe. Risk for fall care plan initiated on 3/31/23 notes R1 will be free from injury related to falls. Intervention implemented on 6/18/23 denotes R1 to remain in common areas when out of bed, to be visible by staff. R1's fall care plan has no intervention following his fall on 5/21/23 to prevent the fall and injury on 5/27/23. Following the fall on 5/11/23 R1 was transferred to hospital for evaluation. The next intervention is dated 5/19/23 to have Physical Therapy re-evaluate R1. 2. R10 is [AGE] years old with diagnosis including but not limited to Fracture of Right Femur (6/21/23), Alzheimer's Disease, Dementia, Stiffness of Joint, Weakness, Delusional Disorders, Restlessness and agitation. R10's cognitive states dated 5/26/23 notes R10 is severely impaired with a score of 3. On 7/27/23 at 10:17AM V29, CNA, said I seen R10 going to the bathroom on 6/18/23. V29 said she it was normal for R10 to get up unassisted to use the bathroom. R10 said when I walked into the room to check on the roommate R10 was on the floor. V29 said R10 did not know how she fell . V29 said R10 said I think she may have slipped on the urine; the floor was wet. V29 said R10 had no bottoms on, her leggings and pull up were not up on R10. V29 said prior to that R10 was calm and sleeping. On 7/28/23 at 12:58PM V13, Director of Nursing, said a leaf on the doorway is a symbol that means the resident has been identified as a fall risk based on the fall risk assessment. V13 said a score of moderate to more risk includes the resident into the fall leaf program. V13 said if a resident falls, they are included in the fall risk program. V13 said the purpose of the program is so staff knows the resident is at risk. V13 said if there is a leaf on the door then staff needs to assist residents when seen standing or walking in the rooms. V13 said the resident may not need staff touch assist but they need staff to at least be present when they have a leaf on the doorway. R10's Fall Scale Evaluation dated 11/22/23 notes a score of 41, moderate risk is scored at 25-44. R10's fall report dated 6/18/23 notes R10 has impaired memory, incontinent and improper foot ware at the time of the fall. On 8/2/23 at 9:34AM V46, MDS Coordinator, said the purpose of the care plan is to provide a road map for care and provide guidelines to help up deliver care to the patient. V46 said the care plan is individualized and reflective of the needs of the patients. V46 said if a fall happens then the care plan would be updated. R10's Investigation Report dated 6/18/23 states at around 4:55AM R10 was observed sitting on the floor. R10 attempted to transfer and ambulate to the bathroom unassisted. R10 said I slipped and fell . X-Rays completed with findings of possible right neck femoral fracture. R10 transferred to the hospital for further evaluation. R10's care plan initiated on 6/22/23 notes R10 status post right femoral neck fracture status post fall. R10's care plan initiated on 5/31/23 states R10 is at risk for falls related to dementia, poor safety awareness, right femur fracture, history of falling, delusional disorder with agitation. Interventions include educate resident/caregivers about safety reminders and what to do if a fall occurs (5/31/23). Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility (5/31/23). These are the only fall interventions listed on the provided care plan prior to the fall on 6/18/23. 3. On 7/25/23 at 10:07AM the surveyor observed R19 self-ambulating out of the bathroom. A leaf is present on the doorway. R19's diagnosis include, but are not limited to, Seizures, Extrapyramidal and Movement Disorder, Tremors, and Unsteadiness on Feet. R19 Fall Scale Evaluation notes a score of 55, high risk is a score 45 and higher. 4. On 7/25/23 at 10:15AM R20 observed walking out of bathroom to the door entryway pushing his wheelchair and wearing a gait belt. No staff nearby. R20's diagnosis include, but are not limited to, Parkinson's Disease and Repeated Falls. R20 had a fall documented on 7/10/23. On 7/26/23 at 10:06AM V32, CNA, said the leaves on the doors mean the resident is on thin liquids. The surveyor asked V32 while clarifying and showing her the leaves on the door, which resemble an orange/red maple leaf, what these mean. V32 again said thin liquids. V32 said R20 can ambulate on his own, but he should be a 1 assist for standing. While speaking with V32 she said R19 needs supervision, like now he is just walking out of the bathroom. V32 remained in the hall with the surveyor and did not approach R19 or the room. V32 said R19 can go in and out the bathroom on his own. The facility Fall Prevention Policy date 11/21/17 states the program will include measures which determine the individuals needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision. Includes: use and implementation of professional standards of practice. Immediate change in interventions that were successful. Communication with staff members. Residents at risk of falling will be assisted with toileting needs. The facility Falling Leaf Program dated 11/28/12 states the team targets select residents who are at risk for falls. Criteria for the program includes impaired safety awareness that has contributed to a fall. Residents identified may have a leaf placed outside their door. The staff will visually check to ensure safety, assist with care needs, and prevent unsafe self-transfers.

Based on observation, interviews and record reviews, the facility failed to ensure that multiple sheets are not used on low air loss mattress, failed to follow treatment orders and interventions in preventing the worsening of pressure ulcer for one (R7) of three residents reviewed for pressure ulcers. This deficiency resulted in R7's pressure ulcer on the sacral region increasing in size and developing slough, necrotic tissue. Findings include: R7 is a [AGE] year-old female, initially admitted in the facility on 09/05/22 with diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Quadriplegia, Unspecified. R7's POS (Physician Order Sheets) documented the following: 4/10/23: Sacrum: Calcium Alginate with Silver as needed for wound care soilage or dislodgement 4/11/23: Sacrum: Calcium Alginate with Silver every day shift for wound care. Cleanse with NSS (normal saline solution), pat dry, apply Calcium alginate Ag, cover with dry dressing. Physician wound notes recorded the following measurements on R7's Stage 4 pressure ulcer on the sacral area: 02/03/23: 5 cm (centimeter) x 8 cm x 1.1 cm 03/02/23: 5.5 cm x 6 cm x 1.5 cm 03/09/23: 6.5 cm x 8 cm x 1.5 cm; History of Present Illness (HPI): Sacral wound size increased compared to the last visit. Surrounding skin was noted with excoriation. 03/16/23: 10 cm x 8.5 cm x 1.1 cm; HPI: Sacral wound debrided to remove devitalized tissue. 04/20/23: 8 cm x 6 cm x 1.5 cm 04/27/23: 8 cm (centimeters) x 6 cm x 1.5 cm On 5/02/23 at 11:00 AM, V13 (Wound Care Coordinator) was observed performing wound care on R7. The sacral pressure ulcer was observed open, with current measurement of 7 cm x 5 cm x 2.8 cm. Per V13, the sacral wound is 30-40% slough, 60-70% granulation. A tan colored slough is covering almost half of the wound bed. During cleansing, the sacral wound was bleeding in minimal amount. Subsequently, the wound was treated as ordered and covered with dressing. R7 was asked if she is repositioned when in bed. R7 stated, I'm not turned every two hours, staff don't do that. My back wound stays the same, been a while. On 05/03/23, R7 was observed for repositioning. The following were noted: 9:20 AM - lying on back 9:40 AM - lying on back 10:05 AM - lying on back 10:20 AM - lying on back. R7 stated she wants to get up because she wants her hair done on the first floor. Also stated that she has not been repositioned. 10:40 AM - lying on back 11:00 AM - CNAs (Certified Nurse Assistants) V6 and V21 were observed going into R7's room. V6 stated that she (R7) wants to be cleaned because she (R7) wanted to go to the first floor to get her (R7) hair done. R7 had to direct V6 to get her up. During provision of morning and incontinence care, as V6 turned her (R7) to her (R7) right side, the brief was observed wrinkled and soiled with minimal to moderate amount of blood coming from the wound. The sacral wound was exposed with no covered dressing. The incontinence pad was also wrinkled and soiled with blood. R7 was using a low air loss mattress covered with a flat sheet. On top of the flat sheet was the soiled incontinence pad. R7 was wearing an incontinence brief. V6 stated, she checked her (R7) around 9:45 AM and she was still dry. R7 verbalized, She checked me, yes but she just asked me how I was doing and if I needed anything. She did not check my brief. She (V6) did not turn me from side to side, never ever. At 11:15 AM, V13 came to clean her wound. V13 stated, We have PRN (when needed) treatment orders, unit nurse can change dressing when needed. CNAs need to tell nurses if the dressing is soiled or been removed during incontinence care. On 05/03/23 at 2:47 PM, V13 was interviewed regarding R7's pressure ulcer on the sacral area. V13 replied, CNAs should notify any new areas to unit nurse. Unit nurse should be doing skin assessment and alerting wound care. Treatment orders should be followed and implemented. Repositioning should be done at least every two hours at the very least. Incontinence care should also be implemented in improving wound status. For low air loss mattress, one flat sheet only. There should be no more than two layers, could be the pad or the brief. Multiple layers would inhibit the functioning of the mattress. R7 should not be wearing the brief. Wound should be covered all the time, to prevent infection. CNAs should be notifying nurses if dressing gets soiled or removed so it could be replaced. R7's care plan on actual impaired skin integrity related to skin breakdown related to decreased mobility and incontinence of bladder secondary to Cervical Spine Injury, current skin breakdown of increased severity, history of Osteomyelitis; potential for signs and symptoms of ongoing and recurrent complications of delayed healing, signs and symptoms of new breakdown, and infection, documented the following interventions: apply treatments as ordered; encourage/assist resident to change position as often as possible; keep skin clean and dry; avoid friction and shearing; specialty bed surface; incontinence briefs/pads, change PRN. V11 (Wound Nurse Practitioner) was asked on 05/03/23 at 1:51 PM about R7's sacral pressure ulcer. V11 stated, Been seeing her for a couple of months now. She has a sacral wound, Stage 4. The wound is stable, no complications from last time I saw her, that was last 04/27/23. She was admitted with Osteomyelitis in the sacral wound. She is incontinent, immobile, and getting a lot of moisture due to her incontinence. It is not okay for the wound not to be covered. She should have a dressing and should be dry all the time. If her wound has 30-40% slough on wound bed, the slough should not be expected on the wound. Presence of slough means there is dead tissue, necrotic tissue and it needs to come off by debridement or medications. V11 stated dead tissue competes with healthy tissue and needs to get out. Slough is not normal but if it's there, it is indicative that tissue is dying, and wound is not improving. Repositioning relieves pressure on the wound and helps in healing. Wound progress notes dated 05/04/23 recorded: Wound measurements sacrum - 8.0 cm x 7.0 cm x 1.5 cm. Manufacturer's guidelines for the use of the low air loss mattress stated in part but not limited to the following: Operating Instructions Step 5 Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient. Facility's policy titled Pressure Ulcer Prevention revision date 1-15-18, documented in part but not limited to the following: Purpose: To prevent and treat pressure sores/ pressure injury. Guidelines: 4. Keep bottom sheet dry and tightly stretched and free of wrinkles. 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated.

Based on interviews and record reviews the facility failed to follow their policy and procedures for fall prevention by not having effective fall interventions, not completing fall evaluations for each fall occurrence to determine root causes of falls, and to ensure proper transfer procedures were implemented for a resident who is totally dependent on staff for transfers. This failure applied to three of three residents (R4, R5, and R9) reviewed for accidents and supervision which resulted in R4 sustaining a spine fracture, R5 sustaining a leg fracture, and R9 experiencing repeated falls. Findings include: R4 is a [AGE] year-old female with a diagnoses and history of Unspecified Injury of Face Subsequent Encounter (as of 03/02/23), Unspecified Injury of Head Subsequent Encounter (as of 03/02/23), Head Bruise Subsequent Encounter (as of 03/02/23), Dementia without Behavioral Disturbance, History of Falling (as of 03/02/23), Abnormalities of Gait and Mobility, Lack of Coordination, and Late onset Alzheimer's Disease who was admitted to the facility 03/02/23. R4's most current physician orders included an active order effective 3/2/2023 for 10mg Donepezil (Cognition Enhancing Medication) by mouth at bedtime for Alzheimer. R4's care plan initiated 03/02/23 documents she is at risk for falls related to unawareness of safety needs, decreased mobility, and recent history of falls with injury with interventions including assure the floor is free of glare, liquids and foreign objects; continue with physical therapy for strengthening, encourage appropriate use of assistive device as applicable, utilizes wheelchair, keep call light and desired personal items within reach, maintain an environment free of clutter, observe for changes in ability to ambulate and/or move about, psych evaluation, recommend that resident use proper footwear, staff will offer and assist patient to rest in bed when noted restless in wheelchair. R4's care plan initiated 03/08/23 documents she is disoriented to person/place/time. Her memory is impaired. She has problems with decision-making, insight, logic, calculation, reasoning, planning, organization, sequencing, social skills and/or judgement. This problem is related to: diagnosis of Dementia with interventions including provide clear explanations regarding expectations and procedures prior to providing care; break tasks down into small, manageable sub-tasks. R4's progress note dated 3/4/2023 at 1:49 PM documents family stressed sun downs and Dementia, reassurance given to family and resident remained sitting up in chair at bedside with no attempts to get up. R4's fall scale evaluations dated 03/02/23, 03/05/23 and 03/30/23 documents she is a high risk for falls with a score of 75 with risks including an impaired gait and a history of falling. R4's post fall observation dated 03/30/23 documents she experienced an unwitnessed fall in the hallway; just prior to fall she was sitting during an unknown activity and using her wheelchair at the time, she was unable to state what happened, no injuries were noted. R4's progress note dated 3/30/2023 12:20 AM documents writer received patient at the nursing station. Patient was very agitated and wouldn't stay in her wheelchair. Patient was hitting the staff, screaming and biting the staff. Family was called and the physician was made aware and asked that the patient be sent out to the hospital; at 6:13 PM documented resident noted sitting at the nurses station in wheelchair screaming, staff attended to all needs and resident was redirected several times. Writer was assisting EMS (Emergency Medical Services) and upon turning to check on resident she was noted on the floor near nursing station screaming and yelling. R4 was noted sitting on her buttocks with the wheelchair sitting behind her. Family requested patient be sent out to emergency room for the fall. R4's progress note dated 3/31/2023 at 08:56 AM documents she was transferred to the hospital due to unwitnessed fall, call placed to hospital. Spoke with nurse at hospital who stated that patient was transferred to another hospital due to cervical fracture. Call placed to other hospital, spoke with nurse who stated that R4 will be admitted for confusion, cervical fracture with cervical collar in place and degenerative changes. Per hospital nurse R4 currently in restraints due to multiple behaviors as she attempted multiple times to get up and is pulling at cervical collar. Facility's Final Incident Investigation Report dated 04/05/23 documents on 03/30/23 R4 was observed sitting up in her wheelchair by the nurses station and was redirected multiple times after attempting to get up from her wheelchair and self-transferring by wheelchair away from the nurses station. R4 was noted to be yelling at staff. Before staff was able to reach her, she stood up and was observed sitting on the floor across from the nursing station. R4 displayed impulsive behavior during the incident and had no safety insight or safety awareness related to diagnoses. R4 was sent to the hospital emergency room for evaluation and a CT scan revealed a cervical fracture. R4's Hospital Record dated 03/30/23 documents she presented at the emergency room after an unwitnessed fall at the facility and was receiving care from a sitter while exhibiting increased agitation. On 05/03/23 from 10:36 AM - 11:26 AM V15 (Licensed Practical Nurse) stated R4 was calmer in the morning but exhibited sundowning daily from 2PM - 11PM. V15 stated R4's sundowning behavior included screaming, not wanting to go to bed or be changed, wanting to walk when she can't, and not wanting to be talked to. V15 stated some days it's possible to get R4 to sit at the nurse's station by her and talk or keep her busy with things like sorting papers or writing stuff out or talking to her about [NAME] and what she liked to do or eat. V15 stated there's always two nurses and four CNA's (Certified Nursing Assistants) that typically work during the 3- 11/11:30 PM shift. V15 stated R4 never refused medication. V15 stated when she arrived to work at 3PM 03/30/23 R4 was already screaming. V15 stated when R4 is sundowning she thinks someone is trying to kill her, and says things like why am I here, and doesn't want anyone to touch her. V15 stated R4 fell around the middle of her shift. V15 stated during the time of R4's fall it was between 6-8 PM during the time medications are being passed and residents are being placed in bed. V15 stated she only remembers her and R4 being at the nurse's station during the time of her incident. V15 stated when R4 fell she had just received a new patient in the facility that had been brought in by EMS (Emergency Medical Services) personnel. V15 stated while she was looking down at documents and completing and signing paperwork for the new resident the EMS driver began communicating with her while he was getting on the elevator. V15 stated she turned her head towards the EMS to communicate with him and when she turned back toward R4 she was on the floor. V15 stated just before R4 fell she was calm and in a low tone asking for her daughter, grandson, and expressing she wanted to go home. V15 stated when the residents come from dinner, the ones who are fall risks are placed by the nurse's station and R4 was sitting by the nurse's station during her incident. V15 stated R4 had refused to be changed so the staff were giving her time before reattempting. V15 stated several times before R4 fell she had to be redirected because she was attempting to get up out of her wheelchair and was up and out of the chair a few times. V15 stated staff had to run over and catch R4 because she was getting out of her chair. V15 stated in order for R4 to comply with sitting down in her wheelchair you have to go over to her or be right next to her. V15 stated R4 was a few feet away on the other side of the nurse's station between the medication room and the water fountain when she fell . V15 stated R4 was not within her reach when she fell . V15 stated she was passing medications when the new resident arrived and had to go and get the paperwork for the new resident and was not directly next to R4 at the time of her fall. V15 stated if she was closer to R4 when she fell , she would have seen her attempting to get up and been able to redirect her. On 05/03/23 from 12:24 PM - 1:50 PM V1 (Administrator) stated residents are supervised from the nurse's station. V1 stated the adequacy of supervision for a resident would depend on the entire plan of care including supervision and depending on the resident's behavior. V1 and V4 (Assistant Director of Nursing) stated R4 may not have been adequately supervised based on her reported behaviors of repeatedly attempting to get out of her chair prior to her fall on 03/30/23 and the nurse reporting R4 will only comply with redirection to remain in her chair when someone is directly next to her. V1 and V4 agreed that it was unlikely that V15 (Licensed Practical Nurse) could reach R4 in time to break her fall based on her distance from the nurse and the barrier of the nurse's station between her and the nurse during the time of her fall on 03/30/23. V1 and V4 agreed that R4's distance from the V15 during the time of her fall could have contributed to her fall. V1 and V4 agreed that V15 turning her head away to attend other duties during the period of time of R4's fall after R4 had been exhibiting behaviors of repeatedly trying to get out of her chair could have contributed to her fall on 03/30/23. R5 is an [AGE] year-old male with a diagnoses history of Partial Paralysis following Stroke, Vascular Dementia without Behavioral Disturbance, History of Falling (as of 08/31/21), and Anxiety Disorder who was originally admitted to the facility 06/08/2021. R5's Quarterly Minimum Data Set, dated dated dated [DATE] documents he requires total dependence on two staff for transfers, extensive one person assistance for bed mobility and toileting. R5's most current care plan initiated 06/29/22 documents he has the potential for vision impairment related to blindness in the left eye; potential for impaired safety with interventions including implement and maintain safety precautions. Tell him (R5) where you are placing his items. R5's most current care plan initiated 06/08/21 also documents he is at risk for falls related to Gait/balance problems, Psychoactive drug use, cognitive deficits, history of falling, CVA Left sided weakness, poor safety awareness, impulsive, limited mobility, poor vision, Anxiety Disorder. R5 has had a fall with no injury on 12/8/21; and he sustained a fall with no injury on 7/24/22 with interventions including: ensure resident is positioned and aligned in the middle of bed; anticipate and meet R5's needs; be sure R5's call light is within reach and encourage him to use it for assistance as needed, R5 needs prompt response to all requests for assistance; Ensure resident is positioned correctly in wheelchair; Ensure that R5 is wearing appropriate footwear when ambulating or mobilizing in wheelchair; he will have a dycem applied to his chair to prevent slipping out of chair. Review information on past falls and attempt to determine cause of falls; record possible root causes; alter remove any potential causes if possible. Educate resident/family/caregivers/ and interdisciplinary team as to causes. R5's most current care plan initiated 07/22/22 documents he requires use of full body lift for transfer with diagnoses history including partial Paralysis and Dementia. R5's most current care plan initiated 01/06/23 documents he is at risk for falls due to Confusion, Incontinence, Poor communication/comprehension, Psychoactive drug use, unaware of safety needs; with diagnosis of partial paralysis following cerebral infarction, vascular dementia, and anxiety disorder with interventions including keep furniture in locked position; Keep needed items, water, etc. in reach; maintain a clear pathway, free of obstacles. Avoid repositioning furniture. R5's progress note dated 03/25/2023 9:15 PM documents CNA (Certified Nursing Assistant) reported to writer patient complaining of pain to right lower extremity. Patient voiced having pain to right leg while being transferred back to bed and during peri care. Assessment completed noted right lower extremity with very painful range of motion. Patient is unable to straighten his right leg and hip/femur is swollen and tender to touch. This writer noted patient sitting up in the chair when arrived this morning. Patient did not complain of pain during day shift and most of PM shift until placed back in bed. Patient screamed out in pain with movement of the right lower extremity. Page placed for the Nurse Practitioner. No incidence of a fall reported for this resident; 10:13 PM progress note documents spoke with Nurse Practitioner; order received to send the patient out to the emergency room . R5's 11:15 PM progress note documents patient with complaints of severe pain to the right hip and femur. Per CNA (Certified Nursing Assistant) patient normally can move right lower extremity and straighten leg on his own without assistance without pain; noted right hip area swelling with excess fluid with pain upon physical medical assessment. Recommendation was to send the resident out to emergency room for evaluation. R5's progress note dated 3/26/2023 09:49 AM documents resident returned from hospital with no new orders alert and awake. No abnormal musculoskeletal findings were observed in hospital assessment. Resident was administered as needed pain medication and transferred to chair to eat breakfast in dining room. R5's 7:38 PM progress note documents that upon further observation of hospital discharge records writer observed that resident refused x-ray of right hip at hospital. Resident continuously complains of pain of right hip. Writer recommends x- ray of right hip. Writer left message for on call service for update, no call back at this time. R5's progress note dated 3/27/2023 10:07 AM documents new orders given by Nurse Practitioner for immediate x-ray to right hip due to complaints of pain. R5's progress note dated 3/28/2023 10:28 AM documents: resident complained of pain when right leg moved, Nurse Practitioner present at facility and examined resident, new orders received for immediate x-rays. R5's 12:03 PM progress note documents x-ray results relayed to Nurse Practitioner of right thigh fracture. New orders to send to hospital. R5's Hospital Record Dated 03/28/23 documents he was admitted for an unwitnessed fall, nontraumatic fracture of right hip, came from nursing home and is not able to give history, was seen in the emergency room two days prior due to right hip pain, it appears that an x-ray was not done at the time of initial presentation to the hospital, an x-ray was performed during this visit to the hospital and revealed a right thigh fracture. R5's progress note dated 3/29/2023 09:49 AM documents he was admitted to the hospital with a diagnosis of Right Thigh Fracture. R5's March 2023 Medication Administration Record documents he was assessed to have a pain level of 7 during the evening shift on Saturday 03/25/23 and during the morning shift on Sunday 03/26/23, and a pain level of 0 from the evening shift on Sunday 03/26/23 - the morning shift on Tuesday 03/28/23. Facility's Final Incident Investigation Report dated 04/03/23 documents on 03/25/23 while providing bedtime care for R5 CNA (Certified Nursing Assistant) observed swelling to R5's right hip, the inability of R5 to straighten his right leg, and appeared to be in pain with movement. R5's Nurse Practitioner was notified, and an order was given to transfer him to the hospital emergency room . On 03/28/23 he was examined by the Nurse Practitioner and an immediate x-ray was performed and revealed an acute right thigh fracture. An order was given to send R5 to the hospital emergency room for further evaluation and treatment. R5 was determined not to have a fall based on interviews with staff and other providers. V16 (Family Member) visited on 03/24/23 and reported no fall incidents. R5 underwent right hip surgery on 03/28/23 at the hospital and remains hospitalized at the time of this report; V22 (Certified Nursing Assistant) was interviewed and stated on 03/25/23 later on during the shift R5 complained of right hip pain when being moved after being transferred to his bed while receiving bedtime care, he was observed with swelling in right hip area and was unable to straighten his leg, the nurse was informed of his condition. A Disciplinary Report dated 03/30/23 included in the investigation packet documents V22 failed to follow care instructions for a resident during transfer and received an immediate warning; a non-dated in-service included in the investigation packet documents V22 was in-serviced regarding following resident's transfer status and care plan; there were no resident interviews other than R5 included in the investigation reports nor any documentation that there were no residents who may have had any direct knowledge of the incident. On 05/03/23 from 12:24 PM - 1:50 PM V1 (Administrator) stated while investigating an injury of unknown origin staff would be interviewed regarding interactions leading up to an injury of unknown origin. V4 (Assistant Director of Nursing) stated you can also interview family, the patient themselves and other residents if they are cognitively able to provide information to determine if they have any information on the potential cause of the injury of unknown origin. V1 stated even if the facility is unable to determine the exact cause of an injury of unknown origin after investigating the cause of the injury, the resident's injury is still the facility's responsibility. On 05/04/23 from 10:27 AM - 10:43 AM V9 (Licensed Practical Nurse) stated R5 did not complain of pain on Friday 03/24/23 when she worked. V9 stated she was off Saturday and Sunday 03/25/23 and 03/26/23. V9 stated when she came back to work on Monday 03/27/23 R5 complained of pain in his legs and an x-ray was done at the facility, but it was inconclusive. V9 stated R5 was still complaining of pain on Tuesday 03/28/23 and the Nurse Practitioner saw him in person and ordered another x-ray. V9 stated another portable in-house x-ray was done on 03/28/23 and it revealed a fracture. V9 stated it seemed like R5's injury happened over the weekend because he did not complain of pain prior to this. V9 stated she believes R5 went to the hospital on 03/25/23. V9 stated R5 only complained of pain when being moved. V9 stated whenever R5's fractured leg was touched then he would report pain. V9 stated R5's complaints of pain were not constant. V9 stated R5 may have a diagnosis of Chronic Pain but did not usually ask for pain medications which is why his complaints of pain leading up to the discovery of a fracture was unusual. V9 stated R5 requires transfer by mechanical lift. V9 stated R5 is usually up in either a reclining chair or high back wheelchair, but she can't be sure which type of chair. V9 stated R5 is normally gotten up daily and has breakfast and remains out of bed. V9 stated R5 is also changed throughout the shift and is placed back in bed in the evening. On 05/04/23 from 1:44 PM - 2:03 PM V4 (Assistant Director of Nursing) stated the nurse should have attempted again to reach out to the doctor to see if R5 would be receptive to being x-rayed after the nurse observed him to be in continuous pain and made an attempt to reach the physician on the evening shift 03/26/23. V4 stated she can't explain what R5's outcome might be from the lack of additional attempts by the nurse to reach the physician on 03/26/23. V4 stated she is not sure why R5's March Medication Administration Record documented pain levels of 0 from the evening of 03/26/23 - the evening of 03/28/23 although his progress notes from 03/26/23 indicated he was in continuous pain. V4 stated she cannot explain how R5 may have sustained his fracture if he didn't fall while in the facility. R9 is an [AGE] year-old male with a diagnoses history of Partial Paralysis following a Stroke, Repeated Falls (present on admission), Dementia without Behavioral Disturbance, Degenerative Disease of the Nervous System and Blindness who was admitted to the facility 07/08/22. On 05/02/23 at 2:19 PM R9 was observed lying in his bed listening to the television. Observed R9 was observed wearing regular socks and R9 had floor mats on both sided of R9's bed. From 05/01/23 - 05/03/23 during the course of the complaint survey while making rounds suveyor did not observe R9 out of his bed and or participating in activities. R9's current care plan initiated 08/29/22 documents he is at high risk for falls related to gait/balance problems, history of falls, and impaired vision with interventions including staff to monitor for altered mental status or acute infection, encourage to call for assistance before attempting to toilet self or transfer, offer and assist to lay down after meals, psych evaluation (initiated 02/28/23), Encourage activities that minimize the potential for falls while providing diversion and distraction, Encourage to participate in activities that promote exercise and physical activity for strengthening and improved mobility, and Physical Therapy to evaluate and treat as ordered or as needed. R9's current care plan initiated 10/03/22 documents he demonstrates behavioral distress as manifested by Verbally abusive behavior; Use of profanity, demeaning statements, verbal threats, and yelling; Racial/ethnic/religious/gender slurs. With interventions including Ask the resident to calmly explain what is causing this upsetting behavior. Praise the resident for speaking calmly and appropriately, If the resident becomes verbally or physically abusive, attempt to calm the resident, by explaining that ladies and gentlemen do not talk or behave this way. R9's current care plan initiated 08/05/22 documents he exhibits the symptoms of rejecting care, places self on ground as a behavior if immediate attention is not given, with interventions including evaluate when the best time of day is to provide care. Provide care consistent with the person's schedule, as possible, give psychoactive medication, as ordered, refer the resident to the consulting psychiatrist for a psychiatric evaluation, as warranted, staff will encourage safe coping skills to help avoid possible falls due to behaviors. R9's current care plan initiated 10/22/22 documents the resident presents with signs and symptoms of Delirium such as recent onset or worsening of symptoms, including becoming easily distracted; paranoia, periods of altered perception/awareness inattention; episodes of disorganized speech; periods of restlessness; periods of lethargy; mental function varying over course of the day. Signs and symptoms are related to: Dementia with interventions including Review medical and psychosocial evaluations to assess potential delirium causes and contributing factors. Delirium is typically caused by several factors. Rule out serious illness/worsening of an acute illness; Review medication interactions. Look for drug toxicity, Review medication and food interaction, Check food and fluid intake. Review weight records. R9's Fall Evaluations from Admission to Current document he is a high risk for falls. R9's progress note dated 08/26/22 documents R9 was observed yelling out repeatedly help me help me I'm on the floor, exhibited signs of confusion and behaviors and it was endorsed to shift to request a psych consult. R9's Post Fall Observation dated 08/26/22 11:30 AM documents he experienced an unwitnessed fall while lying in his bed engaging in leisurely activity in his room. Resident was reaching for call light. R9's progress note dated 10/7/2022 2:05 PM documents patient observed on the floor in his room in a side lying position on the side of the bed. Resident stated that he was attempting to go to the bathroom. Resident with complaints of pain to the right knee. R9's Post Fall Observation dated 10/7/2022 12:40 PM documents he experienced an unwitnessed fall while sitting in his room. Resident stated he was trying to go to the washroom. He experienced pain in his right knee and was provided pain medication. R9's progress note dated 12/22/2022 11:58 AM documents R9 has had a recent fall. Please refer to the Post Fall Observation for details. R9's Post Fall Observation dated 12/22/22 11:58 AM documents he experienced a witnessed fall while sitting in the lounge or dayroom engaging in leisurely activity. R9 stated he was trying to get in his wheelchair to go to bed. R9's progress note dated 12/22/2022 5:03 PM documents at 4:43PM writer notified by day nurse that resident is sitting next to bed on the floor upright, writer walked into room with male certified nursing assistant and noted resident attempting to get up. R9 stated he was reaching for his phone and just sat on floor because felt he was going to fall. R9's Post Fall Observation dated 12/22/22 4:43 PM documents he experienced an unwitnessed fall while in his room lying in bed. R9 stated he was reaching for his phone and just sat on floor because felt he was going to fall. R9 was wearing skid grip socks at the time. R9's progress note dated 12/28/2022 12:57 AM documents writer notified by certified nursing assistant that resident is sitting next to his chair in the day room. Writer walked into room with staff nurses on the floor and noted resident attempting to get up. R9 stated he tried to slide to the floor. R9 started shouting profanity at the staff. Requesting psych evaluation. R9's Post Fall Observation dated 12/28/2022 1:06 PM documents he experienced an unwitnessed fall while sitting in the dayroom or lounge. The resident stated he slid himself onto the floor from his wheelchair. R9's Nurse Practitioner progress note dated 1/2/2023 9:59 PM documents Chief Complaint of Multiple falls. Patient asked to be seen due to multiple falls. Patient sustained a fall twice in a week, noted to be due to behavior issues. R9's progress note dated 1/4/2023 10:02 PM documents Chief Complaint of Multiple falls, now with increased behavior issues. Patient was seen resting on his bed, agitated and anxious at the visit. Patient trying to get up from his bed walk independently, was redirected back to the bed. Patient had sustained to fall recently, will check labs. Assessment and Plan includes increased behavior issue. Other etiology could be worsening dementia as well. Accusing staff of stealing his belongings. Patient with attention seeking behavior. R9's progress note dated 1/21/2023 3:32 AM documents R9 has had a recent fall. Please refer to the Post Fall Observation for details. R9's Post Fall Observation dated 1/21/2023 03:32 AM documents he experienced an unwitnessed fall while in his room lying in his bed sleeping, he was wearing regular socks at the time. R9 reported I don't know what happened and I was trying to get up. R9's progress note dated 2/15/2023 8:12 PM documents Resident is threatening to drop himself on the floor if service request isnt done on time. R9 called a certified nursing assistant for help to get changed but a certified nursing assistant was busy with another patient. R9 pushed himself to the floor to get a quicker response. R9's progress note dated 2/18/2023 6:33 PM documents approximately 6:20 PM during med pass. Writer was reported to by certified nursing assistant that she observed patient lying supine on the floor in the hallway. Writer went to assess R9, and he was still lying supine. R9 was unable to verbalize how he had fallen. R9 unable to verbalize where he was experiencing pain. Nurse Practitioner was notified, verbal order to send R9 to the hospital emergency room . R9's Hospital Record dated 02/18/23 documents he presented to the hospital emergency room from the facility after an unwitnessed fall. R9 was found in the hallway on the ground. Per the emergency medical services personnel R9 stated at the time he was hurting all over. The hospital Registered Nurse spoke with the facility Registered Nurse, and it was reported that he was in significant pain after the fall. R9's progress note dated 2/24/2023 10:04 AM documents Alerted to residents' room, observed resident laying on floor alert verbal complaints of right sided rib pain, resident also stated he bumped his head, R9 is going to be transferring to the hospital emergency room . R9's progress note dated 2/28/2023 07:05 AM documents writer found the resident on the floor upon shift rounds. Resident has confused mental state. Contacted the physician, suggests the resident is sent out for psych evaluation. R9 was transported to the hospital. R9's progress note dated 3/27/2023 5:27 PM documents resident was angry and tried to get out of the bed without any assistance from staff. Resident was observed with his feet on his floor mats sliding himself onto the floor mat. Resident stated he wanted to walk by himself. Resident was re-oriented to ring his call light for assistance out of his bed. R9's progress note dated 3/29/2023 7:18 PM documents Resident was angry and tried to get out of bed without staff assistance. Resident was observed sitting on his floor mat. R9's progress note dated 4/2/2023 2:29 PM documents Writer called to sitting area that resident observed sitting on floor upright. R9's Post Fall Observation dated 4/2/2023 2:31 PM documents he experienced an unwitnessed fall while sitting in the dayroom or lounge during a leisurely activity. He was wearing regular socks at the time. R9's progress note dated 4/18/2023 6:26 PM documents R9 has had a recent fall. Please refer to the Post Fall Observation for details; at 6:52 PM Resident slid himself onto the floor in a rage. The resident was transported from the floor to the wheelchair. R9's Post Fall Observation dated 4/18/2023 6:26 PM documents he experienced a witnessed fall while sitting in the dayroom or lounge during a leisurely activity. Resident stated he was upset he didn't receive a snack immediately and slid himself on to the floor. There were no post fall evaluations completed for R9's falls on 02/15/23, 02/18/23, 02/24/23, 02/28/23, 03/27/23, and 03/29/23. R9's Behavior Diagnostic assessment dated [DATE] documents he is stressed about his money and whether his daughter is taking good care of it, he reports symptoms of frequent depression and less frequently anxiety; staff reports he can be impulsive and this has led to his falling on a few occasions; he is open and receptive to talking with therapist; patient has some dementia but will likely benefit from therapy to cope with losses and his anxiety. R9's Psychological Services Progress note dated 04/20/23 documents he reported being unable to sleep well at night, he sometimes gets very drowsy and has to go lay down. His plan includes visiting with him again in two weeks and provide support as he is coping with the loss of independence particularly his daughter managing his money and his need to get assistance with his ADL's (Activities of Daily Living), will provide an outlet for patient to talk about his concerns. Sessions scheduled every two weeks. R9 expressed appreciation for the opportunity to talk with therapist. On 05/04/23 at 10:22 AM R9 stated he does feel sad and depressed, and it does make him sad that he can't move around the way he used to. R9 stated if he could get a long a little better it would make him feel better. R9 stated he wants to be gotten out of bed and wants to be moved around. R9 stated he would like to be moved around a little more. R9 stated the facility doesn't get him out of bed very often. On 05/03/23 from 12:24 PM - 1:50 PM V1 (Administrator) stated residents are supervised from the nurse's station or if in the television room they are supervised by staff present in the area. V1 stated the adequacy of supervision for a resident would depend on the entire plan of care including supervision and depending on the resident's behavior. V1 stated supervision is adequate for R9 because they can't prevent him from falling and cannot restrain him or limit his movement[TRUNCATED]

Based on interviews and record reviews, the facility failed to follow professional standards of quality care and adequately monitor oxygen saturation levels for one resident (R10) out of three reviewed for change in respiratory status. This failure resulted in R10 being sent to the local hospital for hypoxic respiratory failure. Findings include: On [DATE] at 9:38am, V21 (nurse) stated that V21 does recall R10. V21 stated that V21 does recall that R10 would remove nasal cannula at times. V21 stated that when V21 assessed R10, the nasal cannula prongs were not completely in R10's nose. V21 stated that V21 repositioned the nasal cannula prongs further into R10's nose. V21 stated that V21 does not recall any further details on the event on [DATE]. V21 stated that V21 charted all the details in R10's medical record. On [DATE] at 1:40pm, V37 NP (nurse practitioner) stated that she is unsure reason staff were not monitoring R10's respiratory status and oxygen saturation levels, but staff should be following these facilities policies. V37 stated that V37 would expect staff to be monitoring vital signs, including respirations and oxygen saturation level at least every shift. V37 stated that for residents receiving supplemental oxygenation, the nurse needs to be checking their oxygenation level. V37 stated that if a resident's oxygen saturation level drops to ,d+[DATE]% on oxygen, the nurse should increase the resident's oxygen, remain with the resident to monitor status, and call EMS 911. V37 stated that with nasal cannula, can administer up to 8 liters of oxygen. If more than 8 liters is needed to get oxygen saturation level up into the 90s, the nurse should change to a non-rebreather mask. V37 stated that V37 would have expected the nurse to increase oxygen up to 8 liters and monitor R10's oxygen saturation level to see if it was improving and continue monitoring until EMS paramedics arrived and took over R10's care. Review of R10's medical record, dated [DATE] at 6:00am, V21 (nurse) noted: V21 was called to R10's room by CNA (certified nurse aide) staff, who reported R10 unresponsive. V21 assessed R10 and noted R10 to be very lethargic during assessment and non-responsive to tactile stimuli. R10 had shallow breathing and oxygen saturation level between ,d+[DATE]% at 3 liters oxygen via nasal cannula. Vital signs: blood pressure ,d+[DATE], pulse 80 beats/minute, temperature 97.2 degrees, respirations 14/minute. EMS (emergency medical services) 911 call initiated and paramedics in route. On ,d+[DATE] at 6:16am, V21 noted paramedics x 3 arrived via ambulance and stretcher. R10 remains lethargic at this time with shallow respirations. R10 being transferred to the hospital per paramedics. On [DATE] the nurse noted R10 was admitted with a diagnosis of cardiac arrest. There is no documentation found in R10's medical record noting any interventions (increasing amount of oxygen, continuous oxygen saturation monitoring, monitoring respiratory status) were implemented on [DATE] prior to EMS 911 arrival. Review of R10's hospital medical record, dated [DATE], notes R10 presented to the emergency room at 6:40am. EMS 911 were called for a resident unresponsiveness. Last known normal is unknown. Upon EMS arrival at R10's bedside, R10 had agonal respirations (gasping for air during a serious medical emergency). R10 initially had a heartbeat but then lost it shortly after EMS' arrival. CPR (cardiopulmonary resuscitation) was initiated, and medication administered; return of spontaneous circulation was obtained. R10 remained with no movements and no improvement in mental status. R10's pupils minimally reactive. Distant breath sounds throughout lungs. R10 with generalized edema (swelling) throughout. R10 was intubated and placed on a ventilator. By 9:28am, R10's bilateral pupils were nonreactive and remains unresponsive. R10 expired on [DATE] at 6:40pm, cause of death: hypoxic respiratory failure. Review of R10's EMS run sheet, dated [DATE], notes the facility contacted EMS at 5:53am. EMS crew was dispatched and arrived at the facility at 5:58am. EMS crew at R10's bedside at 6:00am and found R10 unresponsive in bed. R10's respirations were ,d+[DATE] breaths/minute and shallow. R10 was quickly transferred to cot and ventilations were assisted to R10. As soon as R10 was placed in ambulance, R10 went pulseless and without any respirations. CPR was performed and ventilations continued. Return of spontaneous circulation was obtained. R10 remained unresponsive. Review of R10's medical record notes R10 was admitted to this facility on [DATE] with diagnosis including hypertensive heart disease and shortness of breath. Review of R10's medical record notes R10's respirations and oxygen saturation level were last documented on [DATE]. Review of R10's medical record notes V49's (attending physician) last documented face to face visit with R10 was on [DATE]. V37's NP (nurse practitioner) last documented face to face visit with R10 was on [DATE]. Review of R10's chest x-ray, dated [DATE], notes x-ray results were reported on ,d+[DATE] at 11:48pm. Results show infiltrates in both lung bases. This report was reviewed by V50 RN (registered nurse) on [DATE] at 1:15pm. Review of R10's POS (physician order sheet), dated [DATE], oxygen at 2 liters per nasal cannula continuous. On [DATE], notes an order for vital signs every shift x 14 days then daily. On [DATE], notes an order for chest x-ray diagnosis shortness of breath. On [DATE], orders for doxycycline (antibiotic) and Augmentin (antibiotic) oral twice daily times 10 days for pneumonia. There is no documentation in R10's medical record noting reason antibiotics were not started until [DATE] when chest x-ray results were reported on [DATE]. Review of R10's admission physician note, dated [DATE], notes R10 presented to the outside hospital after an unwitnessed fall in the bathroom where R10 landed on both knees. During hospital stay, R10 underwent surgery to both femurs. R10's hospital course was complicated by hypoxia requiring BIPAP and CPAP (both are non-invasive ventilation therapies to treat respiratory distress). R10 was medically stabilized however not yet at her functional baseline and was admitted to this facility on [DATE] for course of subacute rehabilitation. Per V1 (administrator) this facility does not have an oxygen saturation level monitoring policy or an oxygen administration policy.

Based on interviews and record reviews, this facility failed to follow their pressure sore prevention protocols for a resident assessed to be at moderate risk for skin breakdown. This affected 1 of 3 residents reviewed for pressure sore prevention. This failure resulted in R2 developing an unstageable pressure wound 10 days after admission. Finding Include: R2 was admitted in the facility with no skin issue, documented on 12/2/22 as skin intact. R2's Braden scale (Identifies patients at risk for pressure ulcers) score is 13 (Moderate Risk for skin alteration). R2 developed a pressure injury on R2's sacral area documented first on 12/12/22. The facility wound care team seen R2 on 12/13/22, seen by facility wound care nurse. Wound care team noted on 12/13/22 facility-acquired pressure ulceration epithelial or red=20%, slough white fibrous=80%, 5cm (L) x 5 cm (W) x unknown (D). R2 was seen by the Wound Nurse Practitioner on 12/15/22. Initial evaluation reveals unstageable pressure injury on sacrum. There is minimal to moderate amount of serous exudate. Significant contributors include generalized muscle weakness, impaired mobility, and inevitable effects of aging. Initial wound encounter measurements are 5cm x 5cm x 0.1 (L x W x D) treatment was medi-honey and cover with dry dressing change daily and as needed. V2 (DON) documented on 12/12/22, reads in part: Family thanked writer at end of conversation. NP notified of resident's new skin condition, new order received for Tylenol 1000mg q/every 6 hours as needed for pain, low air loss mattress, and ensure to be added to diet due to poor appetite. New orders noted and carried out. Surveyor interview of V2 on 3/22/23, V2 stated that she informed the wound care team at the facility. V2 did not see the wound of R2 and the only orders that was put in place were the three mentioned in her documentation on 12/12/22. V2 does not recall entering any wound treatment order but remembers informing the wound care team of the new skin condition. On 3/14/23 at 1:15pm, V3 (Wound Treatment Nurse) stated R2 skin intact upon admission 12/1/22 and on 12/12/22 identified by the nurse. On 12/13/22 was seen by me (wound nurse). One site, sacrum, unstageable. Measurement 5cm x 5cm, and the depth was unknown. There is a necrotic tissue covering the wound and the depth cannot be determine. Facility provided R2's TAR (Treatment Administration Record) for December 2022 reviewed. Order with a start date of 12/15/22 and discontinued date of 12/16/22, Sacrum: medihoney every day shift every Tuesday, Thursday and Saturday, cleanse with NSS (Normal Saline Solution), pat dry, apply medi honey to sacrum, zinc oxide barrier cream to periwound, cover with dry dressing and this is the first documented treatment for R2's sacral wound, then on 12/17/22, the second documented treatment for R2. No treatment on 12/12/22 when it was initially observed, none on 12/13/22 when the wound care team seen the wound, and none on 12/16/22. There was an order for as needed wound treatment order for sacral, but no signature noted in TAR that as needed order was rendered at all. Facility Policy for Pressure Injury and Skin Assessment with a revision date of 1/17/18, reads in part: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to charge nurse who will perform the detailed assessment. Physician ordered treatment shall be initiated by the staff on the electronic Treatment Administration Record (TAR) after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses noted.

Based on interviews and records reviewed, the facility failed to ensure safety while providing direct resident care. The facility also failed to monitor one resident with history of dysphagia and required one person feeding assistance who was eating ice cream in the hallway to prevent an avoidable fall incident. This affected 2 of 3 (R10, R11) reviewed for safety and avoidable accidents. This failure resulted in R10 rolling out of bed during care and sustaining a left oblique distal femur fracture and a right mildly comminuted oblique distal femur fracture with minimal displacement. R11 fell out of her wheelchair attempting to pick up ice cream cup, sustaining a wrist fracture. Findings include: On 3/22/23 at 11:00am, V2 DON (director of nursing) stated that R10 informed V2 that R10 had a fall while receiving ADL care. V2 stated that V2 had just started working at this facility in September 2022 and was just getting adjusted to facility at the time of R10's fall incident on 10/30/22. When asked to review staff interviews for further details of the incident, V2 stated that V2 did not keep any documented interviews she may have conducted related to R10's fall event while receiving ADL care. V2 acknowledged that any staff interviews V2 may have done should be kept with the fall event. V2 stated that R10 was confused. V2 stated that this facility does not have a post falls policy. V2 stated that there is only a fall prevention policy. On 3/22/23 at 2:25pm, V33 (restorative nurse) stated that V2 DON is responsible for conducting staff interviews to obtain details of each resident fall. V33 stated that the fall protocol is to put immediate interventions in place for the resident then discuss the fall event in IDT (interdisciplinary team) meeting and determine what changes need to put in place to prevent further falls. V33 stated that V33 does not recall R10 or R10's fall on 10/30/22. V33 stated that the nurse should document a fall risk assessment after each fall. V33 stated that if the resident fall occurs when V33 is not present in facility, the nurse is expected to put interventions in place immediately as well as document the event and interventions implemented in the resident's medical record. V33 stated that R10's recent fall with fractures prior to admission to this facility is documented in the fall risk assessment as a history of falls. Review of R10's BIMS (brief interview of mental status) score, dated 10/28/22, notes R10's score was 14 out of 15. Review of R10's MDS (minimum data set), dated 10/28/22 and 1/18/23, notes R10 requires extensive assistance of two staff members with bed mobility. Review of V35's (physician) note, dated 11/1/22, notes R10 had a fall on 10/30/22 per chart, primary physician has ordered x-rays of lumbar spine, right arm, bilateral hips/pelvis, x-rays being taken at the bedside this morning. Pain regimen includes acetaminophen 1000mg (milligrams) twice daily and tramadol (pain medication) as needed. R10 reports pain in bilateral knees, mostly where incisions are located on the anterior and lateral aspects. R10 reports pain is constant and moderate, non-radiating, aching quality and improves somewhat with Acetaminophen/tylenol. On 11/2/22 at 3:12pm, V36 LPN (licensed practical nurse) noted: R10 verbalized that R10 had a fall on 10/30/22 while receiving care with her ADL'S. R10 is now complaining of pain to the right side of her body. Physician was called and left a message in regard to having an x-ray or her right arm and hip. On 11/2/22 at 3:23pm, V36 LPN noted V37 NP (nurse practitioner) gave orders to have an x-ray of bilateral hips and pelvis as well as the right arm. On 11/3/22, V5 ADON (assistant director of nursing) noted order received to include lumbar spine x ray due to R10's complaint of back pain per V37 NP at this time. Order placed, awaiting outside diagnostic imaging company arrival. 11/3/22, V37 NP, R10 seen today due to recent fall, per R10 she rolled out of bed, denies hitting her head, no bruising/hematoma noted on the head, R10 oriented x 3. Slight bruising noted to left neck most likely secondary to nasal cannula pulling when R10 fell . Staff to monitor for changes in mentation, activity intolerance, complains of pain. Maintain facilities fall prevention strategies, follow facilities post fall policy including neurological checks. Monitor neck bruising. There are, no post fall head to toe body assessment or post fall risk assessment documented in R10's medical record after fall on 10/30/22. Review of R10's medical record notes R10 was admitted to this facility on 10/21/22 with diagnoses including right femur fracture, left femur fracture, and history of falling. Review of R10's admission fall risk assessment, dated 10/21/22, notes regarding the history of falling, it is documented 'no'. Review of R10's fall risk assessment, dated 11/23/22, notes regarding the history of falling, it is documented 'no'. Review of R10's fall incident report, dated 11/2/22 at 3:03pm, notes R10 verbalized that R10 had a fall on Sunday, 10/30/22, while receiving care with her ADLs. There is no post fall assessment by the interdisciplinary team to determine root cause of fall to prevent further falls from occurring. Review of R10's admission note, dated 10/22/22, the physician noted R10 presented to the outside hospital after an unwitnessed fall in the bathroom where R10 landed on both knees. Bilateral knee x-rays revealed a left oblique distal femur fracture and a right mildly comminuted oblique distal femur fracture with minimal displacement. Orthopedic surgery consulted, R10 underwent surgery to both femurs. R10 was medically stabilized however not yet at her functional baseline and was admitted to this facility on 10/22/2022 for course of subacute rehabilitation. 39340 R11 was admitted to the facility in 5/27/21 with a diagnosis of alzheimer's disease, dysphagia, dementia hypertension, history of falling, and venous insufficiency. R11's brief interview for mental status dated 2/22/23 documents a score of 3/15 which indicates severe cognitive impairment. Section G under eating documents: 3-Extensive assistance- resident involved in the activity, staff provide weight bearing support and one-person physical assist. R11's dietary slip documents: Aspiration precautions and feeding assistance. On 3/22/23 at 1:13PM, V28 (MDS) stated for minimum data set for eating with a score of 3- extensive assistance and a score of 2- one-person physical assist indicates that resident is being feed by staff. On 3/23/23 at 12:55pm, V20 (speech) stated R11 needs one to one feeding due to dementia, she may not know how to use a spoon or pick up a cup. On 3/22/23 at 3:25pm, V31 (Nurse) stated she observed R11 near the elevator. V31 stated she was on the other side of the nursing station at her medication cart. V31 stated she saw R11 leaning forward and fell out of her chair. R11 was eating ice cream prior to the fall and the ice cream was on the floor and it appeared that R11 was trying to reach the ice cream cup on the floor causing her to fall. R11 complained of pain to her right wrist. On 3/22/23 at 2:16pm, V33 (restorative nurse) stated staff should be monitoring R11 while she is eating in case, she needs assistance or monitoring because she has dysphasia and is at risk for choking. V33 stated the fall on 3/6/23 occurred when R11 was sitting in her wheelchair and fell forward trying to pick up something possibly the ice cream off the floor. V33 stated R11 has no history of falls. R11's facility incident report dated 3/6/23 under description: Resident stated she wasn't sure how she fell . Witness statements: V31(Nurse) dated 3/6/23 documents: writer witnessed the resident fall from her wheelchair onto the floor. Prior to the fall R11 was sitting in her wheelchair eating ice cream. R11 lost her balance and fell forward out of her wheelchair, The resident landed on her right side and stated she had pain to her right wrist, R11 facility final reportable dated 3/9/23 documents: On 3/6/23 at approximately 3:50PM, resident observed by staff sitting in her wheelchair near the nurse's station, eating ice cream from a cup. At approximately 3:55PM, staff observed resident lean forward as if she was attempting to pick something up off the floor. R11 was then observed falling out of her wheelchair on her right side. Ice cream cup noted near resident's foot. R11's radiology results dated 3/6/23 documents: under right hand x-ray impression acute hairline distal radial intra-articular fracture. R11's care plan revised on 6/2/22 documents: R11 has difficulty swallowing and has the potential for choking, aspiration and other adverse events. Interventions revised 11/4/21 documents: Speech therapy recommends diet texture to mechanical soft/thin liquids given close supervision for cues to use general aspiration/reflux precautions. R11's care plan revised on 2/2/23 documents R11 had a functional deficient in her self-performance for eating related to cognitive impairment due to dementia. She requires supervision with verbal cues. Intervention cue/assist R11 to spear food with fork/scoop food with spoon.

Based on interviews and records reviewed, the facility failed to accurately assess residents impaired nutritional status, implement, monitor, and evaluate the effectiveness of interventions for two residents (R3 and R4) reviewed for nutrition and hydration in a sample of 7. These failures resulted in R4 experiencing a mental change in condition and taken the local hospital. R4 was diagnosed and treated for dehydration, critically high potassium level, and acute kidney failure. R3 experienced an unplanned weight loss over a 30-day period without any interventions. Findings include: On 3/17/23 at 11:00am, V2 DON stated that V11 RD (registered dietitian) looks at all residents. V2 stated that the interdisciplinary team meets with V11 weekly to discuss residents. V2 stated that V2 is unsure if R4 was discussed at any of these meetings. V2 stated that recommendations made by V11 are discussed with V2, V8 ADON (assistant director of nursing), dietary manager, and restorative nurse and put in place. V2 stated that all residents are weighed monthly unless V11 recommends weekly monitoring. V2 stated that the staff are expected to document the percentage of each meal a resident consumes. V2 stated that the CNAs are expected to notify the nurse when a resident has poor intake or refuses meal. V2 stated that the nurse is expected to notify the physician and the resident's family when a resident does not eat a meal. When questioned how information is conveyed to nurses/CNAs when there is a recommendation to monitor oral intake. V2 stated that there is no order entered in the resident's medical record; CNAs are expected to document each meal. On 3/14/23 at 2:50pm, V4 (restorative aide) stated that R4 refused breakfast and lunch on 3/11/23 and refused breakfast on 3/12/23. V4 stated that R4 also refused to eat on 3/9/23. V4 stated that R4 did not receive a lunch meal because R4 was transported to the hospital. V4 stated that V4 usually can get R4 to eat sweets and drink coffee, but R4 refused. V4 stated that the rule is to let the nurse know if a resident is not eating. On 3/17/23 at 12:15pm, V4 stated that she took R4's weight on 3/12/23 but did not enter the result in R4's medical record. V4 stated that V4 did not enter R4's weight because R4 went out to the hospital the same day. V4 stated that she is not supposed to enter a weight if the resident goes to the hospital because the resident will be re-weighed upon re-admission. V4 stated that if a resident has a 5-pound weight change, the resident is re-weighed the following day or two. V4 stated that V4 always weighs R4 on wheelchair scale. V4 stated that on 3/12/23 R4's weight was 99.4 pounds. V4 stated that R4's weight was 102.7 pounds on 2/4/23. V4 stated that V4 knew R4 was not eating or drinking and knew R4's weight was off. On 3/16/23 at 12:35pm, V10 CNA (certified nurse aide) stated that V10 was assigned to provide care for R4 on 3/10/23 from 7:00am-3:00pm. V10 stated that R4 did not have an appetite on 3/10/23. V10 stated that R4 usually eats at least 25% of meal offered. V10 stated that R4 loves coffee. V10 stated that on 3/10/23, R4 informed V10 that she was tired and did not want to eat. V10 stated that V10 was able to get R4 to eat a couple of bites, R4 refused coffee. On 3/16/23 at 12:47pm, V12 CNA stated that on 3/10/23 R4 ate less than 50% of her dinner. When asked to clarify the discrepancy between what V12 charted and what V12 is stating about the amount R4 ate on 3/10/23, V12 stated that R4 ate less than 50% of dinner. V12 stated that R4 usually goes to the dining room to eat but on that day R4 did not want to get out of bed. V12 stated that R4 was very tired. V12 documented on 3/10/23 R4 ate 75% of dinner meal. On 3/17/23 at 11:53am, V11 RD (registered dietitian) stated that once monthly weights are done, V11 runs a monthly report and a weight changes report. V11 stated that V11 runs a weekly weight change report. V11 stated that V11 cannot remember if R4 was discussed during weekly interdisciplinary meetings. V11 stated that when she goes to the nursing units, she will ask the nurse if there are any changes. V11 stated that unless staff report any changes to V11, V11 will not know if a resident is not eating. V11 stated that only if a weight change is triggered in the report, V11 will review the amount eaten, interview staff for any changes, and complete an assessment and evaluation. V11 stated that R4's weight for March was not documented in R4's medical record. V11 stated that V11 was unable to review R4's weight and R4's weight loss would not be triggered on weekly weight change report. Review of R4's hospital medical record, dated 3/12/23, notes on previous emergency room visits, R4 had been able to state her name intermittently, answer questions, and answer some basic commands which appears to be changed in today's presentation. R4's initial vital signs taken at 12:47pm: heart rate 109 beats/minute, respirations 18/minute, and blood pressure 174/87. Physical examination noted R4 awake, not oriented, moaning, and not following commands. R4's mucous membranes dry. R4 with increased skin turgor. Potassium critically high at 6.3 (normal range 3.4-5.1), BUN (blood urea nitrogen) level 121 (normal range 6-20), creatinine 11.41 (normal range 0.51-0.95), GFR (glomerular filtration rate 3 (normal is greater than or equal to 60). Diagnoses: acute kidney failure-prerenal azotemia, elevated potassium level, dehydration, altered mental status. Admitting physician's assessment on 3/12/23 notes: R4 is ill-appearing, obtunded (diminished responsiveness to stimuli), cachectic (physical wasting with loss of weight and muscle mass), diffuse muscle wasting of all extremities, including temples, and dry mucous membranes. R4's baseline creatinine level around 1.3. Review of V11's RD (registered dietitian) note, dated 1/30/23, notes R4's estimated needs is 1543-1764 kilocalories, 44-53 grams of protein. R4's appetite is variable per meal records. R4 remains at high nutrition risk. Continue to monitor weight trends, laboratory test results, skin, and oral intake. Review of R4's dietary profile, dated 3/2/23, notes R4's BMI (body mass index) is 19 (R4 is underweight). R4's appetite is fair. R4 has chewing difficulties. Additional risk factors include BMI 20.9 or less. It also notes to monitor weights, skin, laboratory test results, and oral intake. Review of R4's weights notes: 3/12/23, weight was 99.4 pounds. 3.2% weight loss in one month. On 2/4/23, weight was 102.7 pounds On 1/1/23, weight was 103.9 pounds On 12/7/22, weight was 103.2 pounds On 11/2/22, weight was 104.9 pounds Review of R4's care plan, revised 12/19/22, notes R4 is at risk for continued weight loss related to poor appetite. Interventions include notify dietitian if oral consumption is poor more than 48 hours, administer medications as ordered, and provide nutritional supplements as ordered. Review of the amount R4 consumed at each meal for the past three months notes: January 2023, out of 93 opportunities for meals, staff documented 53 meals consumed. On 1/25/23, documentation notes R4 refused meal. February 2023, out of 84 opportunities for meals, staff documented 43 meals consumed. March 2023, out of 36 opportunities for meals, staff documented 11 meals consumed. On 3/11/23, documentation notes R4 refused breakfast and lunch. Review of the National Library of Medicine article dated 8/10/2022, notes azotemia is a biochemical abnormality, defined as elevation, or buildup of, nitrogenous products BUN, creatinine in the blood, and other secondary waste products within the body. Raising the level of nitrogenous waste is attributed to the inability of the renal system to filter (decreased glomerular filtration rate-GFR) such as waste products adequately. It is a typical feature of acute kidney injury. Prerenal azotemia is a subtype of azotemia. Acute kidney injury is generally diagnosed by an increase in creatinine by 0.3 mg/dL, creatinine increase greater than 1.5%. This diagnosis is made with urinalysis, urine electrolytes, metabolic panel and a renal ultrasound. Prerenal azotemia manifests from some insult/injury source before the kidney. Most commonly, we see this in the form of hypoperfusion, or decreased blood flow, to the kidneys from various etiologies of volume depletion, such as dehydration. Review of R3's POS (physician order sheet) notes an order, dated 2/22/23, enteral feedings at 65ml (milliliters)/hour x 12 hours, start at 8:00pm and stop at 8:00am. On 2/1/23, notes orders for dialysis every Monday, Wednesday, and Friday. There is an order for pre- and post- dialysis weights per dialysis center. There also is an order for a liberalized renal diet puree, nectar thick liquids. Review of R3's weight documentation notes: On 3/10/23, R3 weighed 179.8 pounds post dialysis. R3 had a 7.2% weight loss in one month. On 2/10/23, R3 weighed 193.8 pounds post dialysis. On 2/01/23, R3 weighed 190.5 pounds. On 1/10/23, R3 weighed 190.5 pounds. On 1/09/23, R3 weighed 188.7 pounds. There is no documentation found in R3's medical record noting weights were obtained per physician orders. There is no documentation found noting R3 was re-weighed to verify weights. Review of R3's meal consumption, dated 2/13/23-3/12/23, notes there were 84 opportunities for meals. There is documentation of 26 meals consumed by R3. Of these 26 meals, R3 refused meals on three occasions and was not available for two meals. Review of R3's nutrition care plan notes R3 is at risk for malnutrition and dehydration, weights per facility protocol. Review of V11's RD (registered dietitian) note, dated 2/18/23, notes enteral tube feeding provides 65% of estimated nutrition needs. Recent hospitalization ,d+[DATE]-[DATE]. Weight loss noted post hospitalization s. Continues on, dialysis treatment 3/week. Plan: continue with current diet plan of care. Diet appropriate. There is no documentation noting V11 RD was notified of weight loss in one month. There is no documentation noting R3 was hospitalized since January 2023 to explain weight loss. Review of this facility's weight assessment and intervention policy, dated 2020, notes weights are monitored monthly or more often to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Nursing staff will record the resident weight the day they move in, the next day, and once a week for 4 weeks to establish a base weight and stability of weights. Weights shall be recorded in the resident's health record. Interventions for undesirable weight loss shall be based on the nutrition and hydration needs of the resident and the use of supplementation. Review of this facility's hydration monitoring policy, dated 2020, notes residents at risk for dehydration will be identified using the dehydration risk assessment and nutritional screening assessment. Fluids consumed at meals will be documented in addition to meal intake. The nutritional assessment shall reflect factors that put the resident at risk for dehydration as well as interventions to reduce risk factors and ensure adequate fluid intake.

Based on interviews and record reviews, the facility failed to follow their Fall Prevention Program by not implementing appropriate fall interventions to provide necessary supervision for 1 (R357) of 4 residents reviewed for falls in a sample of 30. This failure resulted in R357 falling out of bed unwitnessed on [DATE] at approximately 4:30am and was found on the floor with a head laceration, went into cardiac arrest in the ambulance enroute to the hospital, arrived in the emergency room (ER) as a traumatic cardiac arrest, was found hypoxic with left sided atelectasis, and was pronounced expired at 7:57am with acute respiratory failure due to mucus plug with occlusion of trachea as the cause of death. Findings include: A review of R357's clinical records revealed R357 was initially admitted in the facility on [DATE] and was readmitted from an acute hospital on [DATE]. R357's listed diagnoses are not limited to acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, dependence on respirator [ventilator] status, cognitive communication deficit, weakness, other lack of coordination, and bipolar disorder. R357's physician order sheet (POS) shows R357 was on high-risk psychotropic medication Seroquel 100mg given at bedtime. R357's admission Minimum Data Set (MDS) with assessment reference date (ARD) of [DATE] shows R357 required extensive one staff assist in bed mobility and toileting. R357's Fall Scale Evaluation dated [DATE] shows R357 was at moderate risk for falling. R357's Fall Scale Evaluation dated [DATE] shows R357 was at low risk for falling. R357's comprehensive care plan that was initiated on [DATE] shows R357 is at risk for fall R/T Deconditioning and impaired gait with only these interventions that read in part: Keep call light and desired personal items within reach and Maintain bed in lowest position. R357's Fall incident report dated [DATE] at 4:30am documented by V47 (Agency Nurse) reads in part, Resident observed laying on right side of face near trach accessory tubing. Pool of dark red blood noted under resident. Resident laying with head near right side of the wall next to bed. Feet near foot of bed. Bed in lowest position. Resident opens eyes to verbal command. Resident unable to state what happened. Periods of drowsiness noted. 4 cm laceration noted to forehead. R357's progress note documented by V42 (Respiratory Therapist) dated [DATE] at 7:28am reads, Around 4:40am called to room by nurse. Observed patient/pt on floor, vent alarmed. Both nurses & RT in room, Trach checked, it was patent and tubing intact. Nurse took vitals, and recorded SPO2 87% and began bagging pt with 100% oxygen. She had altered mental status. 911 was called, pt out to hospital. Facility's fall incident investigation on R357 documents in part: A witness statement from V61 (Certified Nursing Assistant/CNA) documents R357 on [DATE] was observed getting back into bed without assistance from using bed side commode. A witness statement from V45 (Certified Nursing Assistant) dated [DATE] documents that R357 was last seen at 2:30am while rounding and R357 was observed getting back into bed from using the bedside commode unassisted. A witness statement from V47 dated [DATE] documents at 4:30am V47 noticed R357's call light/ventilator alarm were sounding. V47 went into R357's room and observed R357 on the right side of R357's bed. A review of R357's Emergency Department (ED) triage notes dated [DATE] at 5:44am reads in part, Pt came from nursing home due to fall. Pt has a left sided facial laceration. Pt lost pulse while in ambulance. Emergency Medical Services/ EMS began CPR (no epis given). Trauma at bedside. Pt has a trach and is chronically vented. A review of R357's ED provider notes dated [DATE] at 9:06am revealed R357 was brought in as a traumatic arrest and initially managed by the trauma team. R357 reportedly fell out of bed at the nursing home and was found on the floor with a head laceration. R357 went into cardiac arrest in the ambulance enroute to the hospital. R357 arrived as a traumatic cardiac arrest and was found hypoxic with left sided atelectasis. R357 was pronounced dead at 7:57am. A review of R357's death certificate dated [DATE] shows acute respiratory failure due to mucus plug with occlusion of trachea as the cause of death. On [DATE] at 11:44am, V10 (Registered Nurse 2nd Floor Manager) was interviewed and stated that R357 was high risk for falling. V10 stated that R357 used the bedside commode for toileting and needed one staff assistance. V10 stated that at times R357 would get up without assistance and forgets to call for help when needed. V10 stated that R357 had no bed alarm. At 12:02 pm, V38 (Certified Nursing Assistant) was interviewed and stated that V38 had taken care of R357 while in the facility. V38 stated that R357 gets confused at times and would get up by herself but was not supposed to. V38 stated that R357 would sometimes forget how to use the call light. V38 stated that R357 was using a bedside commode for toileting needs and was doing it by herself but was not supposed to because it was not safe for R357. V38 stated R357 needed assistance with incontinence care. At 12:13pm, V9 (Respiratory Therapist) was interviewed and stated that R357 was on a full support ventilator and was very, very anxious. V9 stated that respiratory therapists (RTs) and the nurses should be monitoring the residents' ventilators. V9 stated that if the ventilators are not working properly, it would alarm. On [DATE] at 7:16am, a phone interview conducted with V42 (Respiratory Therapist). V42 stated that V42 was the RT assigned to R357 on [DATE] until 7:00am. V42 stated that R357 did not sleep that night. V42 stated that at around 4:00am, a nurse called V42's attention to R357's room because R357 fell from the bed. V42 stated, I saw [R357] was bleeding on [R357] forehead. On [R357] middle forehead. [R357] was lying on [R357] right side on the floor by [R357's] bed. I immediately checked the vent. The tubing was not disconnected. The nurse turned [R357] and cleaned the [R357], I checked the vent it was working properly and no other issues. [R357] right hand was lying over the trach tubing. I removed the hand from the tubing. [R357's] saturation was near about 94%. Nurse called 911 right away within 10 mins they came. [R357] was okay when 911 picked [R357] up. [R357's] heart rate was up but [R357's] saturation was ,d+[DATE]%. At 11:18am, a phone interview conducted with V45 (Certified Nursing Assistant) and stated that V45 was the CNA in-charge of R357 from [DATE] night shift until [DATE] in the morning. V45 stated that V45 was on break when R357 fell out of bed. V45 stated that V45 went on break from 2:30am and came back at 5:00am. V45 stated R357 needed limited assistance from staff to use the bedside commode. V45 stated that R357 was on her (R357) phone all night that night. V45 stated R357 used the call light if needed but sometimes forgets and would get up by herself. At 11:36am, V2 (Director of Nursing) was interviewed and stated that fall risk assessment are done on resident's upon admission and after a fall. V2 stated that fall a care plan is initiated on admission and updated if there is a fall and based on the MDS calendar. V2 stated that fall interventions should be based on the nursing assessment and the resident's history. V2 stated that R357 came back from the hospital on [DATE] and R357's fall care plan was not revised. V2 stated that an appropriate fall intervention for R357 would be to remind R357 to call for assistance unless R357 was strong enough as far as therapy goes, but these were not indicated in R357's fall care plan. V2 stated, As far as I'm aware the staff did not let [R357] use the commode on her [R357] own but [R357] was observed not calling for help and staff would re-direct every time when they see [R357] transferring on her [R357] own. Surveyor asked V2 to provide documentation indicating education and re-direction were provided to R357. V2 stated that the education and re-direction were done verbally and would not be documented. On [DATE] at 11:49am, interviewed V33 (Staffing Coordinator) and stated that nursing staff can go on break for 30 minutes and a 15-minute quick break but not at the same time. V33 stated that more than an hour break is not acceptable. At 2:11pm, a phone interview conducted with V59 (Nurse Practitioner), V59 stated V59 took care of R357 while in the facility. V59 stated that R357 had tracheostomy and was too anxious. V59 stated that R357 had the tendency to not call for help when needed. V59 stated that R357 had a decline with R357's debility and needed more assistance. V59 stated that R357 fell , was sent out to the hospital, and expired. V59 stated V59 does not know R357's cause of death. Surveyor asked V59 that if a resident is on full support ventilator, fell with head trauma and wound development could that be contributory factors for a resident to have acute respiratory failure. V59 answered, Yes definitely. At 3:33pm, V50 (MDS/Care Plan Coordinator) was interviewed and stated that fall risk assessments are done first upon admission and the care plan should be implemented based of that, if the resident has history of fall, on psychotropic medications, and based on what type of assistance the resident needs. V50 stated that the resident's comprehensive care plan should be completed up to 21 days from admission. V50 stated that if a resident is at risk for falling and has the tendency to get up without assistance and is not supposed to, that problem should be included in the fall care plan. V50 stated that the care plan interventions should include based on the resident's risk factors that have been identified based on resident's assessment, staff observations, fall assessment, review of records, and resident and family interviews. V50 stated that the care plan should address what the staff assess from the resident because the purpose of the care plan is to guide the plan of care of the resident. V50 stated that the care plan is also used for communication so the staff would know what the needs, preferences, and concerns of the resident are. V50 stated that care plan interventions should be implemented based on what the staff establish from the resident, and it would be specific based of whatever the concerns of the resident are. V50 stated, If it's a fall care plan the interventions should be based on whatever the problem of the resident. It should include something that we know of about the patient. V50 stated that if the care plan is incomplete, the staff might not be able to adequately decrease the risk of the resident from falling and the staff won't be able to know the plan of care of the resident. V50 further stated that the resident's care plan should also be reviewed upon re-admission. Surveyor called V47 and left messages on these dates and times but to no avail: [DATE] at 7:12pm, 11:28am; and [DATE] at 7:40am and 3:20pm. V47 was the agency nurse in charge for R357 when the fall incident happened. The facility's policy titled; Fall Prevention Program revised on [DATE] reads in part: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Standards: Safety interventions will be implemented for each resident identified at risk. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. The facility's policy titled; Comprehensive Care Plan revised on [DATE] reads in part: Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to prevent an injury of unknown origin for 1 of 3 residents (R19) reviewed for abuse. This failure resulted in R19 having multiple unexplained bruises under the left eye, left shoulder and left forearm. Findings Include: On 11/30/22 at 10:16am, V67 (R19's family member) stated, R19 mouthed and pointed to V3 (certified nursing assistant/CNA), stating you hit me when V3 walked into the room on 11/24/22. R19 accused V3 (CNA) of hitting her in the face and pinching her. The incident had to happen on 11/23 when I didn't visit. I spoke to V3. V3 stated, I did not hit R19. I would never hit R19. I love R19. I would never hurt R19. V16 (respiratory therapist) told me, R19 eyes looked swollen. I reported it to V4 (nurse). V79 (emergency medical technician/EMT) stated, R19 had a black eye. I told R19 we couldn't prove the abuse but R19 keeps reporting the same thing. V3 is usually nice and takes care of R19 but something must have happened because R19 kept mouthing and writing V3 abused her. On 12/01/22 at 11:10pm, V69 (R19's family) stated, R19 had a black eye. V68 (R19's family member) stated, R19's right eye was red and puffy. R19 said, V3 did it. On 12/01/22 at 12:39 pm, V79 (EMT) stated, R19's face was bruised up on both sides. Right side face was bruised, left cheek circular 1cm bruise area. On 12/6/22 at 3:00pm, R19 was assessed to be alert and oriented to person, place and time. R19 stated V3 (CNA) started hitting(slapping) pinching me two weeks after I arrived at the facility. I didn't tell anyone because I was afraid V3 was going to retaliate. V3 would get upset because I would push the call light. V3 slapped my hands, both sides of my face and pinched my stomach. R19 demonstrated where and how she was being hit and pinched by making a pinching motion over her stomach (lateral right side) and a slapping motion to the back of the hand and face on both cheeks with the front/palm-side of her hand. R19 was observed with two dissipating red circular spotted areas under R19's eye bags (puffy areas under R19's bilateral eyes on the lateral side). R19's left lateral eye was observed with a dissipating blue crescent area similar to the shape of a crescent moon under R19's left eye bag/puffy area. R19 had a bruised/dissipating blue irregular shaped area on the left shoulder the size of a 5-cent coin, and a larger blue dissipating area that covered R19's bicep with two circular dissipating blue circular area underneath the bicep just above the antecubital space and a dark irregular square shape on the posterior arm located at the base of the tricep above R19's elbow. Hospital paperwork dated 11/25/22 documents: Diagnosis: Suspect Elder Abuse. Skin: Bruising present. When ask is she (R19) felt scared to return to her nursing home. R19 nodded her head yes. Abuse Policy: Facility abuse prevention program policy revised 1/22/19 documents: It is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and crime against a resident in the facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, means the individual must have intended to inflict injury or harm. Physical abuse: hitting, slapping, pinching, kicking, etc.

Based on interview and record review, the facility failed to immediately report and remove an elastic band from around one residents' legs which was placed by a family member. The facility failed to monitor a resident in respiratory distress, notify the physician to obtain treatment orders for a critical high white blood cell count, failed to identify/notify the physician to obtain treatment orders for an alteration in skin around the implanted venous port and failed to implement interventions to prevent skin breakdown from moisture associated dermatitis. These failures affected 4 of 4 residents (R15, R4, R16, and R9) reviewed for quality of care. These failures resulted in R15 developing blisters to bilateral lower extremities, R4 being treated for elevated white blood cells for 3 days and being transported to the local hospital to be evaluated, diagnosed , and treated for sepsis. These failures also resulted in R16's implanted venous port dehiscence and R16 having to be transported to the local hospital and R9 developing full skin thickness skin loss. Findings include: R15 was admitted to the facility on [DATE] with diagnoses of Anoxic Brain Damage, Acute Respiratory Failure, Dysphagia, Gastrostomy, and Tracheostomy. R15's emergency service report dated 11/6/22: Emergency Medical Service (EMS) crew was dispatched to patient location for trouble breathing. Upon arrival the EMS crew found patient alone in room with no nursing staff present. Patient appeared to be aspirating on liquid food, heavy wheezing and posturing. Nursing home respiratory therapist came into the room and stated that patient was suctioned at approximately 4:00am this morning and patient was not in distress. The respiratory therapist suctioned R15, while suctioning was taken place EMS crew noticed R15's legs were bound by a rubber band across both legs. At no point during patient care at bedside did a nurse come into the room. The EMS crew only received information from the respiratory staff and face sheet. History and vital signs taken advanced life support (ALS) care started. After suctioning EMS crew bagged patient with bag valve mask and patient's oxygenation levels improved from 71% to 97%. ALS care continued. Patient loaded into ambulance where ALS care continued. On 11/9/22 at 11:15am, V26 (fire department personal) state he responded to 911 call for R15. V26 stated when they arrived to R15's room there were no staff monitoring or attending to R15. The respiratory therapist came in the room shortly after they arrived and assisted with suctioning the patient. V26 stated upon transferring R15 to the stretcher, EMS observed R15's lower legs were bound with a black elastic band on bilateral thighs above the knees. The band appeared to be indented into R15s skin. The elastic band was removed by EMS and reported to facility staff. R15's hospital record dated 11/6/22 documents: EMS stated that upon arrival, the patient's legs were bound with physical therapy band. They report the nurse did not show up when they arrived. Under Emergency triage notes: Per EMS upon arrival patient was in severe respiratory distress with oxygenation at 78% on trach collar. EMS states patient condition was extremely poor. EMS also states patient had a resistance band around her thighs binding them together. R15's legs observed with red welts with blistering from where patient was restrained. On 11/16/22 at 10:50am, R15 was observed in bed. Resident legs observed to be contracted in a butterfly pose. R15's Bilateral arms and hand contracted to the body. There were several small open and scabbed areas on right upper leg and one scabbed area noted to left upper leg. On 11/17/22 at 11:11am, V65 (R15's family) stated she saw R15 around 10:00am on 11/5/22. V65 stated she placed the band around R15's legs to help exercise but her ride arrived early. V65 stated, there was a CNA on the other side of the room assisting with care to the roommate and she asked her to remove the band from R15. V65 stated she then left. On 11/9/22 at 305PM, V21 (CNA) identified as CNA for R15 on 11/5/22 7:00am-3:00pm shift. V21 stated she did not observe the band on R15 when she provided morning care. V21 said she recalls family visiting R15 in the morning and after they left V21 said she observed the band on R15's legs when providing care. V21 said she did not report it to anyone because she thought it was supposed to be on R15. On 11/10/22 at 312PM, V21 said that no one asked her to remove the bands from R15. On 11/9/22 at 3:48pm, V29 (CNA) stated she worked with R15 for the evening shift (3pm-11pm) and overnight shift (11pm-7aam on 11/5/22 into 11/6/22. V29 stated she observed the band on R15's legs during her shifts and stated she was able to provide incontinence care with no concerns. V29 stated she reported the band to V28 ( nurse) at the end of her first shift and the nurse just said okay. V29 stated the nurse did not give any further instructions and assumed the band was meant to be there. V29 stated she assumed other people had seen the band. V29 stated she saw blisters on R15's knees. On 11/22/22 at 2:26pm, V55 (CNA) stated she was the CNA working the 11pm-7am shift on 11/5/22 into 11/6/22 . V55 stated she heard V29 (CNA) asking the nurse about the bands on R15 and why were they there. V55 stated there was no response from the nurse. On 11/9/22 at 2:16pm, V28 (nurse) was identified as the nurse working with R15 11pm-7am shift on 11/5/22 into 11/6/22. V28 stated around 7am she went to give R15's morning medications and observed R15 in distress. R15 had emesis and pulse oxygenation was in the eighties. V28 stated she yelled for oncoming nurse who called 911 and the respiratory therapists, they were trying to clear R15's airway. V28 stated she stepped away to get R15's paperwork. V28 said she did not observe the band on R15 and said no one reported to her about the band on R15's legs. On 11/10/22 at 11:37am, V19 (Respiratory therapy, RT manager) identified as RT working with R15 on 11/5/22 into morning of 11/6/22. V19 stated she was performing change of shift report with V63 (RT) when she observed paramedics exiting the elevator on R15's floor. V19 stated she was not made aware that R15 was experiencing respiratory distress prior to EMS arrival. V19 said V28 (Nurse) was at the nursing station and reported that R15 was having a change in condition. V19 stated they went with EMS to R15's rooms. V19 stated she is unable to recall if any other facility staff were present in the room with R15 at time of EMS arrival to R15's room. V19 stated R15 was in distress and suctioning was performed. R15's oxygenation was 79% on 5 liters of oxygen. We increased oxygen to 15 liters and pulse ox went up to 91%. V19 denies seeing any bands on R15's legs. On 11/10/22 at 2:43pm, V34 (restorative aide) stated R15's family showed her the bands back in October. V34 stated she told the family the bands were not appropriate and no further discussion. V34 said she reported it to V35 (restorative nurse). On 11/10/22 at 238pm, V35 (restorative nurse) stated she spoke to R15's family in October. V35 stated family had inquired about placing bands on R15's legs due to contractures. V35 said she told family facility could not place bands on R15 because it would be a restraint and family said okay. There was no further discussion about the bands. V35 stated the conversation was documented on a on grievance form. Review of R15's medical record did not document any education or discussion with family about the use of bands around her legs. Review of facility grievance binder for September and October did not document any grievance related to R15. R15's wound assessment report dated 11/12/22 documents: right lateral knee; blister measuring 18x13x0.10cm; left anterior thigh; blister measuring 1x1xunknown cm. R4 was admitted to the facility on [DATE] with a diagnoses of Respiratory Failure, Protein-Calorie Malnutrition, Chronic Kidney Disease, type II Diabetes, Pressure Ulcer and Anemia. R4's progress note dated 10/19/22 at 11:36am documents: Spoke local hospital who stated that resident was evaluated, and they found no emesis when assessed. Resident noted to have elevated white blood count and chest x-ray was clear per emergency room (ER) nurse. Resident will not be admitted and will return back to facility. R4's progress note dated 10/20/22 at 1:19pm documents: R4 had emesis times(x)3. Vital signs stable. New orders for x-ray. R4's Physician order sheets documents order 10/20/22 referral for Gastroenterologist and stat KUB for vomiting. R4's laboratory results dated [DATE] documents: white blood count of 28.7. Results phoned and faxed on 10/21/22 at 1:47pm. Normal white blood cell count range is 4.8-10.8. R4's laboratory results dated [DATE] document white blood cells 14.7. R4's progress note 10/22/22 documents: Writer called patient's primary doctor to relay critical labs; could not reach MD; writer will pass labs onto the next shift nurse to recontact MD. R4's progress note 10/23/22 at 5:58pm documents: This writer left message with the on-call number to relay labs, awaiting call back. R4's progress note 10/23/22 at 8:05pm documents: Note Text: Lab results were relayed, MD gave orders to monitor. R4's progress note 10/24/22 at 3:56pm documents: V61 gave orders for patient to be seen by infectious disease for elevated white blood count. R4's Physician order sheets documents order on 10/24/22 referral for infectious disease. There were no other orders documented related to high White blood count. R4's medication administration record for October 2022 does not document any new treatments after 10/19/22. R4's vital signs were monitored once a day. R4's hospital record dated 10/24/22 documents: White blood count of 46.7. Under clinical impression documents: Sepsis due to unspecified organism and pneumonia due to infectious organism in part of the lung. R4's care plan dated 9/16/22 documents R4 has potential to exhibit signs and symptoms of infection related to chronic leucocytes. History of C.Auris fungemia, Enterococcal Bacteremia and Klebsiella; recent history of urinary tract infection. Interventions: assess for signs and symptoms of infection. Notify the physician as indicated; notify physician of change in condition; obtain laboratory results as ordered. Report abnormal reports to physician; obtain vital signs as ordered. On 11/23/22 at 9:45am, V60 (MD) and V61 (NP) stated they both do not recall being notified of any abnormal lab results for R16. V60 stated if he was notified of results, they would have monitored the patient. When asked to explain what monitor means, V60 said he would expect the staff to monitor R4's vital signs every shift and report any changes or abnormal values. V60 said any further interventions would depend on how the patient was presenting clinically and if no changes presented, they would just continue to monitor the patient. When V60 was asked if any additional diagnostic test should have been ordered, V60 replied that it was too soon to reorder CBC and he has never had any issues with laboratory results in the past. V60 said he may have ordered a blood culture but that takes a few days so it would have been easier to send the patient to the hospital at that point. V60 stated they did order KUB to be performed due to emesis and there were no findings. V61 stated she referred R16 to infectious disease on 10/24/22 prior to hospital transfer. On 11/22/22 at 2:53pm, V2 (DON) stated facility staff should notify the physician immediately for any critical lab results. If doctor is not available, they would reach out to the medical director to report results. On 11/23/22 at 9:39pm, V25 (Medical director) stated If she or her staff would have been notified of high WBC results, staff would have ordered additional labs for following day, possibly order chest x-ray, urine collection, blood cultures and reach out to infectious disease. V25 stated an elevated White blood cell count can led to sepsis if not treated. R16 admitted in the facility on 9/27/22 and was discharged on [DATE]. Hospital record of R16 reviewed upon initial admission to the facility dated 9/27/22, under past surgical/procedure shows IR CVA Port Insertion on 8/29/22. R16 went for chemotherapy appointment on 11/1/22. Facility documentation dated 11/1/22 reads in part: Call received from nurse at appointment, per nurse stated that R16 would be admitted to hospital thru ER (emergency room ) due to R16's current status. Nurse was not able to give admitting diagnosis. Per nurse R16 was noted with low blood pressure, R16 noted with complications to port a cath site upon removal of dressing. Hospital record dated 11/1/22, R16 presented in the hospital with tachypnea, hypoxic and dehiscence implanted port. R16 was found unresponsive while still in the ER and then admitted in MICU (Intensive Care Unit). On 11/16/22 at 1pm, V5 (Unit Manager) stated I believed R16 was in his appointment and the clinic informed me that R16 will be admitted to the hospital from his appointment due to blood pressure being low and complication with the porta cath. If I don't put it on my notes, I do not recall what was the venous port complications. I was not present when R16 left for R16's appointment and I just received a call when the nurse from the clinic had called to inform us that R16 is going to the hospital. On 11/17/22 at 11am, V28 (Oncologist Personnel) stated R16 was in our office on 10/7/22 and the porta cath site was fine, and on 11/1/22 appointment, we saw a band aid covering the port cath site. Removed it and noted the skin around the port has deteriorated. Skin surrounding the port is open and you can see the port. The site is clean and no bleeding, so I assumed someone from the facility is aware about the site and had cleaned it and put a band aid over it. R16 was sent to the hospital because of this skin opening surrounding the port. They are high risk of infection, for anyone with port implanted on them. On 11/17/22 at 10am, V2 (DON) V5 did not report to me or if V5 did, I dent remember if V5 reported to me R16's conditions when the oncologist office called that day. For any new skin alterations. We notify the doctor, family and the wound care team. They have to document new skin alteration and must be assessed to have proper treatment. Wound care team need to evaluate new skin alteration. On 11/18/22 at 10:30am, V7 (Wound Nurse) stated that R16 was admitted with skin breakdown to his sacral, unstageable. Sacral skin alteration healed before R16 left the facility, healed on 10/28/22. I did not know any other skin issues with R16 besides the sacral site that healed in October. I am not aware of any skin opening on his chest implanted port site. My expectation is for the staff to notify the doctor, family and the wound care team. It would be a concern to me if the port site is open, implanted port site is expected to be under the skin, with the skin intact. With skin opening around the port site, it should have a treatment order to prevent further complications. R16's facility physician order sheet reviewed and there is no noted order for any treatment for implanted venous port skin alterations. R16's progress notes reviewed from admission 9/27/22 to 11/1/22, and there is no noted wound/skin alteration related to the implanted venous port site/area. R16's TAR (Treatment Administration Record) did not show any treatments for skin alteration related to implanted venous port site/area. Facility policy titled Pressure injury and skin condition assessment revised 1-17-18 documents: Each resident will be observed for skin breakdown daily during care and on assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified. 41758 Braden score dated 8/6/22 documents: R9's score as 12 which indicates high risk for acquiring pressure wounds(range 10-12) due to sensory (slightly limited), moisture (very moist), activity (chairfast), mobility(very limited) nutrition (probably inadequate) and friction/shear (problem). Preventive recommendation: Moisture-none. On 11/3/22 at 9:58am, V82 (R9's family) stated, R9 would call me on his mobile phone, ask me to call the nursing station so R9 could be cleaned after a bowel movement. R9 had to wait two hours to be cleaned. On 11/22/22 at 3:56pm, V58 (wound doctor) stated, R9's moisture associated dermatitis (MASD) was related to R9 being incontinence. R9 was left in feces and urine every two hours. When R9 was repositioned every two hours he was soiled. On 11/22/22 at 4:17pm, V58 said, an adult brief can worsen an area with MASD. The adult brief can dig into the impaired skin. On 11/22/22 at 4:27pm, V7 (wound nurse) stated incontinence can cause MASD. On 11/23/22 at 10:30am, V59 (wound nurse practitioner) stated, R9's skin etiology started off as moisture associated dermatitis. With constant moisture of the skin and exposed/impaired skin being traumatized by the adult brief can lead to subcutaneous tissue being loss. R9's wound picture dated 8/17/22 was observed with slough. R9's wound should have not been classified a MASD but as full thickness loss (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) I would have debrided R9's wound and packed it depending on the depth after the debridement. Wound assessment dated [DATE] documents: R9 had bilateral thighs moisture associated dermatitis which was facility-acquired. Clinical stage: Partial Thickness (Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough.) Wound doctor assessment dated [DATE] documents: Wound #4 Right thigh is a MASD, measurements are 10cm length x 0.5cm width x 0.1cm depth (LxWxD), with an area of 5 sq cm and a volume of 0.5 cubic cm. Wound doctor assessment dated [DATE] documents: Wound #5 Left thigh is a MASD, measurements are 10cm length x 0.5cm width x 0.1cm depth (LxWxD), with an area of 5 sq cm and a volume of 0.5 cubic cm. Care plan revised on 8/17/22 documents: Bilateral Thigh- MASD- incontinence care as needed, and skin barrier applied and turn and reposition.

Based on interview and record review, the facility failed to immediately notify a physician of a critical high white blood cell count result for one resident (R4) of three residents reviewed for abnormal labs. This failure led to a delay in care that resulted in R4 being transferred to the hospital with a diagnosis of Sepsis. Findings include: R4 was admitted to the facility on [DATE] with a diagnoses of Respiratory Failure, Protein-Calorie Malnutrition, Chronic Kidney Disease, type II Diabetes, Pressure Ulcer and Anemia. R4's laboratory results dated [DATE] documents: white blood count of 28.7. Results phoned and faxed on 10/21/22 at 13:47pm. Normal white blood cell count range is 4.8-10.8. R4's laboratory results dated [DATE] document white blood cells 14.7. R4's progress note 10/22/22 at 6:50am documents: Writer called patient's primary doctor to relay critical labs; could not reach MD; writer will pass labs onto the next shift nurse to recontact MD. R4's progress note 10/23/22 at 5:58pm documents: This writer left message with the on-call number to relay labs, awaiting call back. R4's progress note 10/23/22 at 8:05pm documents: Note Text: Lab results were relayed; MD gave orders to monitor. R4's progress note 10/24/22 at 3:56pm documents: V61 gave orders for patient to be seen by infectious disease for elevated white blood count. On 11/23/22 at 9:45am, V60 (MD) and V61 (NP) stated they both do not recall being notified of any abnormal lab results for R16. V60 stated if he was notified of results, they would have monitored the patient. When asked to explain what monitor means, V60 stated he would expect the staff to monitor R4's vital signs every shift and report any changes or abnormal values. V60 continued by stating any further interventions would depend on how the patient was presenting clinically and if no changes presented, they would just continue to monitor the patient. When V60 was asked if any additional diagnostic test should have been ordered, V60 replied that it was too soon to reorder (complete blood count) CBC and he has never had any issues with laboratory results in the past. V60 stated he may have ordered a blood culture but that takes a few days so it would have been easier to send the patient to the hospital at that point. V60 stated they did order (kidney, ureter, bladder) KUB to be performed due to emesis and there were no findings. V61 said she referred R16 to infectious disease on 10/24/22 prior to hospital transfer. On 11/23/22 at 10:26am, V60 (MD) stated he reviewed the on-call service report and there was no call received by the facility during the time documented in the progress notes by the facility. On 11/22/22 at 2:53PM, V2 (DON) stated facility staff should notify the physician immediately for any critical lab results. If doctor is not available, they would reach out to the medical director to report results. On 11/23/22 at 9:39am, V25 (Medical director) stated she does not recall being notified of critical laboratory results for R4. If she or her staff would have been notified of high WBC results, staff would of ran additional labs for following day, possibly order chest x-ray, urine collection, blood cultures and reach out to infectious disease. If no of those things are documented, we may not have been notified of results. Facility policy titled Physician - Family notification- change in condition revised 11-13-18 documents under purpose: to ensure that the medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient and effective manner. The facility will inform the resident, consult with the resident's physician or authorized designee such as nurse practitioner, notify the residents legal representative when there is: a significant change in the resident's physical, mental or psychosocial status. A need to alter treatment significantly.

Based on interviews and record reviews this facility failed to include and initiate enteral feeding upon admission to the facility. This affected 1 of 1 resident reviewed for neglect. This failure resulted in R6 being admitted to the nursing home and not fed for over 24 hours. Findings include: Review of R6's medical record notes R6 was admitted to this facility on 8/5/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's medical record, dated 8/5/22 at 2:46pm, the admission nurse noted R6 with G-tube. Physician paged, awaiting call back. There is no documentation found in R6's medical record noting R6's physician was contacted for enteral feedings via G-tube. Review of R6's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's MAR (medication administration record), dated August 2022, notes enteral feeding via G-tube initiated on 8/6 by the night shift nurse (11:00pm-7:00am). Review of R6's admission dietary profile, dated 8/5/22, notes R6 is receiving nutrition via G-tube (gastrostomy). R6 is nothing by mouth. R6's nutritional needs will be met and will be free from dehydration. Continue current diet management and see V12 RD (registered dietitian) as needed for follow-up. Review of R6's pre-admission form, dated 8/1/22, notes R6 is receiving enteral nutrition via G-tube. Review of R6's hospital discharge notes, dated 8/4/22, notes R6 is nothing by mouth. R6 is receiving enteral nutrition at 50ml/hr with water flush at 40ml/hr via G-tube. Review of R6's MDS (minimum data set), dated 8/12/22, notes R6 is totally dependent on staff for bed nutrition. On 9/11/22 at 12:30pm, V13 (complainant) stated R6 was admitted on [DATE] with no orders for G-tube (gastrostomy tube) feedings until 8/6 at 4pm. V13 stated R6 appeared like R6 was losing weight. When V13 asked staff to weigh R6, V13 was informed R6 is weighed monthly. V13 stated that V13 spoke with V9 NP (nurse practitioner) regarding concern of weight loss. V13 stated that R6 weighed 105 pounds. On 9/12/22 at 12:10pm, V9 NP (nurse practitioner) stated V9 would expect the nurse to contact V12 RD (registered dietitian) for G-tube feeding orders. V9 stated in the hospital, the R6 may have been receiving a different formula than what is available at this facility and the Nurse should contact V12 to see if the formula should be changed. V9 stated V9 would expect the nurse to call the physician for G-tube feeding orders if V12 was not called. V9 stated nutrition is important for all residents that receive G-tube feedings. V9 stated that on 8/30 V9 spoke with R6's family. At that time, the family expressed concern for weight loss. V9 stated that V9 notified restorative staff to weigh R6. V9 stated that R6's weight was 105 pounds. V9 stated that on 8/30 V9 notified V12 RD to re-assess R6's nutritional needs.

Based on interviews and record reviews, this facility failed to accurately assess a resident's impaired nutritional status, implement, monitor, and evaluate the effectiveness of interventions; failed to follow its policy and procedures for weekly weight monitoring for newly admitted residents (R5, R6, R7, and R8) out of 4 residents reviewed for changes in weight. This failure resulted in R6 had a 10.3% weight loss in 25 days without any nutritional intervention. Findings include: 1. R6: Review of R6's medical record notes R6 was admitted to this facility on 8/5/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's admission weight, dated 8/9/22, was 117 pounds. Review of R6's medical record, dated 8/5/22 at 2:46pm, the admission nurse noted R6 with G-tube. Physician paged, awaiting call back. There is no documentation found in R6's medical record noting R6's physician was contacted for enteral feedings via G-tube. Review of R6's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/6 at 3:23pm, R6's POS notes an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/22, R6's POS notes an order to weigh R6 as soon as possible, family is concerned that R6 is losing weight. Review of R6's MAR (medication administration record), dated August 2022, notes enteral feeding via G-tube initiated on 8/6 by the night shift nurse (11:00pm-7:00am). Review of R6's pre-admission form, dated 8/1/22, notes R6 is receiving enteral nutrition via G-tube. Review of R6's hospital discharge notes, dated 8/4/22, notes R6 is nothing by mouth. R6 is receiving enteral nutrition at 50ml/hr with water flush at 40ml/hr via G-tube. Review of R6's admission dietary profile, dated 8/5/22, notes R6 is receiving nutrition via G-tube (gastrostomy). R6 is nothing by mouth. R6's nutritional needs will be met and will be free from dehydration. Continue current diet management and see V12 RD (registered dietitian) as needed for follow-up. Review of V12's RD (registered dietitian) note, dated 8/9/22, notes: diet: nothing by mouth; enteral feeding 50ml/hour x 24 hours; water flush via G-tube 320ml every shift. Estimated needs: 1595-1861 kilocalories, 80-106 grams protein. Skin: deep tissue injury to right ear. R6 dependent on enteral nutrition for total nutrition support related to dysphagia. Tolerating feeding well. Reviewed hospital records, receiving enteral feeding 50 ml/hr x 24 hrs, water flush 40 ml x 24 hours (960 ml). R6 at nutrition risk related to comorbidities. Plan: continue with current feeding order. Enteral feeding appropriate. Monitor feeding tolerance, skin, labs, weight. V12 to follow up as needed. Review of R6's MDS (minimum data set), dated 8/12/22, notes R6 is totally dependent on staff for bed nutrition. There is no documentation found in R6's medical record noting V12 was re-consulted when R6 developed a pressure ulcer on 8/17 and two pressure ulcers on 8/23 to reassess R6's nutritional needs. On 9/11/22 at 12:30pm, V13 (complainant) stated that R6 was admitted on [DATE] with no orders for G-tube (gastrostomy tube) feedings until 8/6 at 4pm. V13 stated that R6 appeared like R6 was losing weight. V13 stated that V13 spoke with V9 NP (nurse practitioner) regarding concern of weight loss. V13 stated R6 weighed 105 pounds. On 9/11/22 at 12:00pm, V12 RD (registered dietitian) stated that all residents should have an initial weight done upon admission and then weekly x 4 weeks. V12 stated that it is important to obtain weekly weights to monitor resident's adjustment to this facility, meal consumption, and progress. On 9/12/22 at 12:10pm, V9 NP (nurse practitioner) stated V9 would expect the nurse to contact V12 RD (registered dietitian) for G-tube feeding orders. V9 stated in the hospital, the R6 may have been receiving a different formula than what is available at this facility and the Nurse should contact V12 to see if the formula should be changed. V9 stated V9 would expect the nurse to call the physician for G-tube feeding orders if V12 was not called. V9 stated nutrition is important for all residents that receive G-tube feedings. V9 stated on 8/30 V9 spoke with R6's family. At that time, the family expressed concern for weight loss. On 8/30/22, V9 notified restorative staff to weigh R6. V9 stated R6's weight was 105 pounds. V9 stated that on 8/30 V9 notified V12 RD to re-assess R6's nutritional needs. On 9/12/22 at 12:50pm, V10 (restorative nurse) stated that V10 started at this facility one week ago. V10 stated that this facility had one restorative aide for a while to weigh all of the residents. V10 stated that the aide had difficulty obtaining weights on residents as ordered. V10 stated the protocol is to obtain a resident's weight upon admission/re-admission and then weekly x 4, then monthly. V10 stated that some residents have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. R5: Review of R5's medical record notes R5 was admitted to this facility on 5/13/2022. Review of R5's POS, dated 5/16/22, notes an order to weigh upon admission and weekly x 4, every day shift every 7 days for 5 weeks. Review of R5's weight documentation notes R5 was weighed on 5/13, 6/16, 7/1, and 8/1. There is no documentation found in R5's medical record noting R5 was weighed on 5/20, 5/27, 6/3, or 6/10. 3. R7: Review of R7's medical record notes R7 was admitted to this facility on 7/13/2022. Review of R7's POS, dated 7/14/22, notes an order to weigh upon admission and weekly x 4. Review of R7's weight documentation notes R7 was weighed on 7/21 and 8/9. There is no documentation found in R7's medical record noting R7 was weighed on 7/14, 7/28, or since 8/9. 4. R8: Review of R8's medical record notes R8 was admitted to this facility on 5/11/2022. Review of R8's POS, dated 5/11/22, notes an order to weigh upon admission and weekly x 4. Review of R8's weight documentation notes R8 was weighed on 5/12, 6/3, 6/9, 7/1, and 8/1. There is no documentation found in R8's medical record noting R8 was weighed on 5/19, 5/26, or since 8/1. Review of this facility's weights policy, revised 10/17/2019, notes each resident shall be weighed on admission and at least monthly thereafter. Residents identified at nutritional risk may be weighed weekly or bi-weekly per physician order.

Based on observations, interviews, and records reviewed the facility failed to ensure staff used a full body mechanical lift per the manufacturers recommendations to ensure the machine is balanced during 3 resident (R3, R4, R12) transfers. In addition, the facility failed to identify 2 residents (R3, R4) of 3 residents requiring the use of a mechanical lift for transfers. This failure has the potential to affect 58 residents transferred with the full body mechanical lift. This failure resulted in R4 suffering a closed head injury. The facility also failed to develop a plan to prevent or reduce the risk of an avoidable accident of dislodging a temporary [CONDITION(S)] catheter for a resident with involuntary jerking movements. This affected 1 of 1 resident R9 reviewed for accidents and incidents. This failure resulted in R9 dislodging the temporary catheter and sent to the local hospital for replacement. The immediate jeopardy began on 6/22/2022 when R4 was allowed to fall during a transfer and removed on 7/27/2022. V5 (Administrator) was informed of the immediate jeopardy and the immediate jeopardy template was presented on 7/22/22 at 2:20PM. The facility provided an initial removal plan on 7/22/22 and the plan was not accepted on 7/26/22. The facility presented a modified removal plan on 07/27/22 and the plan was accepted on 7/27/22. An onsite investigation was conducted on 7/27/22 to confirm the implementation of the facility's remove plan. However, the deficiency remains at a level 2 harm until the facility can review the effectiveness of their removal plan. Findings include: A. R4 is [AGE] years old with diagnosis including but not limited to Ventilator Associated Pneumonia, Acute and Chronic Respiratory Failure with [CONDITION(S)], Acute Kidney Failure, [CONDITION(S)] Status, Respiratory [Ventilator] status, Attention to Gastrostomy, Dysphagia, Metabolic [CONDITION(S)], Morbid (Severe) Obesity. R4's Cognitive Pattern assessment dated [DATE] notes she is severely impaired. On June 20, 2022 R4's weight was 420 pounds. On 7/13/22 at 3:46PM V7, Certified Nursing Assistant (CNA), said she was assigned to R4 on 6/22/22. V7 said V10 and V11, both CNAs, assisted her during R4's transfer from the bed to the chair with the full body mechanical lift. All 3 CNAs (V7, V10, and V11) said the facility has trained them on the use of full body mechanical lifts. V7 said while preparing R4 for the transfer she and V11 attached the sling hooks to the machine. V7 said V10 was managing R4's devices and tubes. V7 said I was running the machine and V11 was at the patient's side. V7 said when they were ready, with the mechanical lift over the bed, and R4 in the sling, she began pressing the button to raise R4 up and I got R4 in the air off the bed. V7 said I then started pulling the lift back away from the bed. V7 said that is when the mechanical lift started tipping to the side. V7 said V11 placed the chair under R4, and she was lowered into the chair before the lift tipped further. V7 said after R4 was in the chair, I saw color forming and a raised areas on R4's right temple area. V7 said the area remained closed. The surveyor followed V7 to the unit to have her show me the mechanical lift used. On 7/13/22 at 3:00PM V7 with V10 showed the surveyor the mechanical lift used on R4. The lift has a sticker on it indicating a 450-pound capacity. V7 said she knew it was this lift used on R4 because it's the big one. V7 said R4 weighed 410 pounds so we have to use the big machine. V7, V10, and V11 demonstrated the events of the transfer that occurred on 6/22/22 without a resident connected to the lift. V7 demonstrated how the mechanical lift would have been placed t like from the bed with the legs of the lift under the bed in the closed position. V7 and V11 demonstrated how the sling would be hooked to the machine. V7 showed after she pulled the lift away from the starting point the mechanical lift's legs started to lift to one side leaving the lift to balance on the opposite leg. V7 said when the lift was tipping R4 was no longer over the bed. V11 said she moved the chair under R4 while in the air and then V7 pressed the button to lower R4 into the chair. V7 said R4 hit her head on this part of the mechanical lift and placed her hand over the arm or arch of the lift, above the attachment hooks. V7 said after she pulled R4 away from the bed the legs on the lift remained in the closed position. V7 said the mechanical lift's legs are only extended when you are going into the chair, then they open. R4's functional status assessment dated [DATE] (6/22/22 is part of the 7 day look back for the assessment) notes R4 requires a minimum extensive assistance for activities of daily living. The facility Report to IDPH Regional Office Final Report Summary states while transferring resident from bed to wheel chair accompanied by three CNAs, using a full mechanical lift, the lift began to tilt. R4 assessed and noted to have a raised area with discoloration to the right side of the forehead. R4's hospital Clinical Impression notes closed head injury without loss of consciousness. B. R3 On 7/14/22 at 11:44AM V14 and V15, both CNAs, observed using the full body mechanical lift to transfer R3 from her bed into an electric wheel chair. V14 pushed the mechanical lift under R3's bed with the lift's legs in the closed position. V14 and V15 then hooked the sling, with R3 in it, to the lift. V14 operated the machine and pulled the lift away from the bed and maneuvered it to the electric wheel chair. While R3 had no surface under her, and the lift had been maneuvered away from the bed, the legs of the mechanical lift remained closed. Once at the chair, then V14 opened the lift's legs. R3 was then lowered into her chair. On 7/14/22 at 2:28PM V10, Restorative CNA, said she trains new staff on the use of mechanical lifts. V10 said when training staff she demonstrates how the lift is to be used. V10 said the mechanical lift legs are left closed and how wide the legs will open depends on the width of the chair you are transferring the person into. On 7/15/22 at 9:45AM V12, Restorative Nurse, said I have not trained the staff on the use of the full body mechanical lift use. V12 said R4 was assessed to require the use of the full body mechanical lift for transfers. V12 said she did not see a transfer care plan identified for R4. V12 was asked to explain the use of the full body mechanical lift to the survey, as V12 would train staff on the use of the lift. V12 said when the full body lift's legs are under the bed, the staff should open the legs as easing out from under the surface and close the legs. V12 said the staff should start to close as pull out the lift from the bed. V12 said the legs position depends on obstacle dealing with, such as furniture and room size. V12 said if the legs are not in the proper position the lift may tile. The surveyor asked questions to clarify the position the lift legs should be in and V12 said it all depends on the obstacles in the rooms. On 7/15/22 at 1:41PM V1, Director of Nursing, said if a transfer assessment is not done and there is no care plan for the transfer status of a resident, then the staff will not know how to transfer them. V1 said R4 required a full body mechanical lift for transfers and is should have been in the care plan. V1 said following R4's closed head injury she spoke with the CNAs involved and they showed her they were trying to put R4 in her chair. V1 said the CNAs told her R4's head was bumped. V1 said the injury was caused by maybe her weight was disproportion, [R4's] weight not distributed evenly. V1 said the legs on the mechanical lift help to keep the machine balanced. V1 said the legs are able to be adjusted. V1 said when she investigated the cause of R4's injury I did not ask about the position of the legs. On 7/16/22 at 2:29PM V16, Restorative Corporate Nurse, was interviewed by phone by the surveyor. The surveyor asked V16 what position the full body lift machine legs should be in when a resident is in it and being moved to a wheel chair. V16 responded when the full body mechanical lift is used for transfers it should have the legs wide open. V16 said the purpose of opening the legs is to provide a wide base of support, V16 said because we need balance so it will not tip over. C. On 7/27/22 at 1:12PM the surveyor observed V44 and V45, both CNAs, preparing to transfer R12 from his bed into his wheel chair. A letter H observed on the wall over R12's bed. The surveyor observed the legs on the full body mechanical lift to be opened while positioning the device under the bed. The surveyor observed as the transfer was initiated and R12 was being connected to the transfer sling the legs on the lift were closed under the bed. When R12 was connected to the full body mechanical lift, fully lifted off the bed, and the CNA pulled the mechanical lift away from the bed, the legs on the lift were closed. The CNA turned with R12 in the lift to her left and completed a half circle turn to position the resident over his wheel chair. Once nearing the wheel chair the CNA opened the legs of the mechanical lift. The mechanical lift legs were closed while R12 was away from the bed and wheel chair. There was no obstacle from bed to wheel chair preventing the legs from being opened. The care plan provided by the facility for R3 created on 3/17/22 has no transfer status identified. Review of the facility provided mechanical lift transfer training record does not state legs should be open on full body machine. This training records was reviewed for V10, dated 5/18/22; V11, dated 12/14/21; V15 and V7, both undated. On 7/20/22 the facility provided a list titled Midnight Census Report dated 7/19/22 and R3 is indicated as requiring a full body mechanical lift transfer. R12 is indicated as requiring a full body mechanical lift transfer. [indicated with letter H per interview with V10.] There are a total of 58 residents indicated on this list as requiring a full body mechanical lift. The facility provided an undated mechanical lift user manual that states on page 20, Warning the legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. The surveyor confirmed through observation, interview and record review that the following actions to remove the immediacy: 1 DON and assigned licensed nurse staff (EG) assessed R3 for alleged improper transfer, full body assessment initiated. No open areas, no bruising, no c/o pain. (Completed 7/22/22, Exhibit 1) 2 R4 is no longer a resident within the facility. 3 Nurses/CNA's in-serviced by an outside consultant (Assurance) on safe resident handling on mechanical lifts according to the manufactures recommendation (Invacare), competencies, and observation on safe transfers. Initiated on 7/22/22 and continues to remain ongoing (See exhibit #2) 4 Revised (7/26/22) Outside Consultant from Assurance was called in to in-service and train agency and nursing staff (nurses and CNA's) on the use of a mechanical lift (Invacare) per the manufacturer's recommendation starting immediately and will be ongoing. (7/22/22 and will continue until completion date of 7/26/22, on-going for agency staff) 5 Outside Consultant initiated the competencies on safe resident handling with mechanical lifts. Competencies will be completed by all agency & clinical staff before reporting to assigned units immediately. (7/22/22 and on-going, Exhibit #3) 6 Revised (7/26/22) The DON/Restorative staff/nurse supervisors will also provide training, in-servicing and competencies for agency and nursing staff (nurses and aides) on the use of the mechanical lift (Hoyer) per the recommendations. The Hoyer manufacturer usage will be given to each agency nurse, nursing staff (nurses and aides) post training. (7/22/22 and will continue until the completion date of 7/26/22.) 7 The DON/Restorative staff/nurse supervisor will provide in servicing and training for agency and nursing staff (nurses and aides) who have not been scheduled to work (PRN staff), vacation, or medical leave. They will be required to complete (Hoyer) in-service, training, and competencies prior to reporting to their assigned units. (7/22/22 and on-going upon an employee scheduled return to work). 8 Revised (7/27/22) The DON/Restorative staff/nurse supervisor will provide in servicing and training for newly hired nursing staff (nurses and aides) who have not been scheduled to work. They will be required to complete the mechanical lift (Hoyer) in-service, training, and competencies prior to reporting to their assigned units. (7/27/22 until scheduled to start work.) 9 Revised (7/26/22) Clinical nursing staff members including agency staff will not be permitted to work until they have been in-serviced, trained, and completed competencies on proper mechanical lift usage immediately. (7/22/22, completion date for facility nurses and aides 7/26/22, agency nurses will be on-going) 10 Clinical staff including agency will be able to verbalize and demonstrate how to properly balance and use the mechanical lift during transfers. 11 Revised (7/26/22) DON/unit managers will randomly observe safe transfers of residents using the mechanical lift twice weekly via an audit tool starting immediately. (7/22/22 and on-going exhibit #4) 12 (Revised 7/27/22) The DON/Restorative staff/nurse supervisors will provide re-in servicing for agency, nursing staff (nurses and aides) on proper mechanical lift usage immediately. (7/27/22 initiated will continue until completion on or before 7/29/22). 13 (Revised 7/27/22) The DON/Restorative staff/nurse supervisors will perform mock mechanical lift (Hoyer) transfer training with return demonstration for all agency, nursing staff (nurses and aides), prior to each shift to ensure proper usage immediately 7/27/22 until completion date on or before 7/29/22. 14 Revised (7/26/22) The Restorative Consultant will review transfer assessments/resident observations to determine residents transfer ability. Initiate and revise care plans as appropriate based on residents needs for assistance. (7/22/22 initiated will continue until completed on 7/26/22.) 15 Revised (7/26/22) DON/restorative assistant will indicate the residents transfer ability and post it over the resident's bed for proper identification of transfer ability. (7/22/22 initiated and on-going.) 16 The Restorative Consultant/restorative nurse will initiate care plans upon admission, quarterly and as needed to indicate the residents transfer needs. (7/22/22 and on-going.) B. R9 face sheet shows R9 has medical diagnosis of myoclonic movements, attention for [CONDITION(S)], gastrostomy, dependence on renal [CONDITION(S)], acute kidney failure with tubular necrosis, non-pressure chronic ulcer of other part of right foot with unspecified severity, non-pressure chronic ulcer of other part of left foot with unspecified severity, history of sudden [CONDITION(S)], [CONDITION(S)], history stroke, dysphagia, hypertension, CAD, seizures, End stage renal disease, and bilateral Femur Occlusions. On 7/14/22 at 3:30p.m V18 (R9 family) said R9 [CONDITION(S)] fistula came out of his arm and R9 had to go to the hospital to have it replaced. On 7/15/22 at 1:25p.m. R9 was observed with a catheter on the right upper chest covered with white dressing. Review of R9 records, R9 does not have a [CONDITION(S)] fistula, R9 has temporary [CONDITION(S)] catheter in place. On 7/15/22 at 2:23p.m. V19 ([CONDITION(S)] manager) said R9 has a temporary catheter in place for hemodialysis, V19 said R9 was brought down to [CONDITION(S)] room on an unknown date and R9 [CONDITION(S)] port-a-cath was pulled out of place but it was not entirely out of the chest. V19 said sometimes a catheter can get pulled out if it is does not have sutures in place. V19 said the sutures do come out, they are not permanent. V19 said the catheter system also has a balloon in place to help prevent the catheter from being pulled out. V19 said sometimes that system fails. V19 said only the [CONDITION(S)] nurse can change the dressing on the catheter and the facility nurse should not touch the catheter. V19 said due to the position of the catheter the staff may not necessarily see that it is pulled out place because the gown would cover it. V19 said he cannot say that the facility staff pulled the catheter out of place or R9 pulled the catheter out of place because R9 does a motion with his arm and flexes his arm. V19 said R9 could have pulled the catheter himself. V19 said R9 did not have any adverse events and R9 did not miss [CONDITION(S)]. V19 said R9 was admitted to the facility with the catheter and the hospital would make sure catheter is properly place before initial use. V19 said R9 catheter was properly placed and used for hemodialysis. On 7/19/22 at 1:20pm V2 (DON) said she will look into information regarding the occurrence of R9 [CONDITION(S)] catheter. V2 said an incident report was not completed for this occurrence. V2 said the staff should use standard nursing care when providing care to a resident with a temporary catheter. V2 said standard care is making sure the catheter does not get tangled during care. R9 progress notes dated 5/11/22 shows resident sent to hospital in stable condition and dressed appropriate for the weather r/t (related to) dislodged permacath ([CONDITION(S)] catheter). MD and Mother made aware. R9 has plan of care in place for kidney failure and myoclonic movements. Review of R9 plan of care there is not plan of care on place for the observing for and ensuring that the catheter don't get tangled. Upon exiting this survey V1 did not present any information regarding this incident related to R9 catheter being dislodged. Review of R9 plan of care, there is no plan of care in place for R9 temporary catheter, no plan of care in place on how the facility plan to ensure that the catheter is not dislodged in the future, no plan of care in place for monitoring and ensuring the catheter is not tangled in anything during care. Facility policy Titled dated 11/28/12 with approve date of 4/7/2019 shows in-part the incident/accident report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in [NAME], allegations of theft and abuse registered by residents, visitors or others and residents-to- residents altercation. An incident defines as any happening, not consistent with routine operation of the facility, that does not result in bodily or property damage. Physical or mental mistreatment (abuse-actual or suspected) of a resident is considered an incident whether actual injury has occurred. An accident is defined as any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident/ accident report will be completed for all serious accidents/ incidents of residents, all unusual occurrences, all situations requiring the emergency services of a hospital, the police fire department or coroner, any condition resulting from an accident requiring first aid, physician visit, or transfer to another health care facility.

Based on observations, interviews, and records reviewed the facility failed to follow their pressure sore prevention policy and procedure by not obtaining treatment orders of new skin breakdown and following the manufactures recommendation for the use of the pressure relieving mattress, and reporting missing dressing during care. This failure affected 3 of 5 (R2, R13, and R19) residents reviewed for pressure sore prevention protocols. This failure resulted in R2 developing Stage 2 and Stage 3 pressure ulcers within 72 hours before treatment orders were obtained. Findings include: A. On 7/14/22 at 12:25PM R2 said regarding her buttocks, it [CONDITION(S)] when they change and if I move. When V29, Certified Nursing Assistant (CNA), turned R2 onto her right side R2s brief had 2 bright red spots and then an open area was noted on R2's right buttock that was bleeding bright red blood. V29 said I reported this open area to the nurse on Monday or Tuesday. V29 said she had seen the open area on R2's buttocks, when she reported on Monday and Tuesday, while providing R2 with morning care. V29 continued with incontinent care on R2. R2 was crying during care and a second open area was noted near R2's tail bone area. R2 was not using devices to offload pressure on her heels. The surveyor did not observe an air pump at the foot of the bed to indicate a special mattress was in use for R2. On 7/14/22 at 12:52PM V21, LPN, said there were no concerns related to R2 reported today. V21 said she has not performed any assessments on R2. On 7/15/22 at 11:30AM V2 (Wound Care Coordinator) said, we have to do an assessment on R2, today, she has something on her skin. V2 said the nurse working today entered it into the charting system. V2 said R2 did not have that area yesterday. V2 said R2 was admitted in May with a stage 2 (pressure ulcer) that healed on 6/16/22. V2 said on admission a low air loss mattress, that has a pump was implemented. V2 said if the CNA sees an open area, they should notify the nurse. V2 said the nurse should call the doctor, get orders, and document the skin condition. V2 said the nurse should assess the wound and then we (wound care team) will look at it. V2 said R2 and R3 should have something in place to offload pressure on their feet, a pillow, blanket, or boots. On 7/19/22 at 11:01AM V2 said after looking at R2 on 7/15/22 she has a stage 2 pressure ulcer on her sacrum and a stage 3 pressure ulcer on her right ischial. V2 said the right ischial pressure ulcer has more depth so she staged it as a stage 3. V2 said the first time she was made aware that R2 had skin impairment was on 7/15/22. V2 said it is possible the pressure ulcers were a stage 1 or 2 before she was notified. V2 said if the floor nurse was notified that there is a skin impairment, she should have called the doctor and started a treatment. V2 said if a treatment had been initiated for R2 it could prevent her from developing a stage 3. V2 said the wounds are measured and staged when reported to be able to track the progress of the wound. V2 said at this time she has no way of knowing if the wound improved or declined since the CNA first saw it. R2's care plan initiated on 5/27/22 notes R2 has Stage 2 pressure ulcer to coccyx and remains at high risk for further skin breakdown. R2's Wound Assessment Details Report notes the coccyx wound was closed on 6/23/22. On 6/16/22 the Wound Assessment Details Report notes remains on low air loss mattress and heels offloaded while in bed. A Skin Observation Report dated 7/13/22 for R2 notes redness on buttocks/coccyx/sacrum area. R2 has no wound orders on her orders or Treatment Administration Record until July 15, 2022 to treat her Sacrum or Right Ischial. Wound Assessment Details Report assessment dated [DATE], same as identified date, for R2's right ischial notes Stage 3 measuring 2.5 x 6.0 x 0 (Length x Width x Depth). A second wound report with the same dates noted a Stage 2 measuring 1.0 x 1.8 x 0.0 on R2's Sacrum. B. On 7/14/22 at 10:29AM R13 observed in her bed on an air mattress that has a pump at the foot of the bed. The pump is turned on and set at static and 200. On 7/14/22 at 10:49AM V25, Wound Nurse, observed providing care to R13's left foot. The surveyor observed when V25 pulled the cover away and R13 had no dressing on her left foot or pressure relief devices. V25 said R13 should have a dressing on her left foot, but someone removed it. V25 said the air mattress should be set to the resident's weight. V25 said R13's mattress pump should be set to alternative and at the second bar, about 120 pounds and R13 is set at 200. V25 said R13's pump should be set lower. V25 said they (CNAs) move it and forget to change it after the resident care is provided. V25 completed R13's wound care and applied a dry dressing and kerlix over the left foot. When V25 had finished R13's left foot was covered from heel to toes with white dressing. No off loading was provided to R13's feet after V25 had completed wound care. On 7/14/22 at 11:16AM V20, LPN, said no one informed her today that any resident needs or is missing wound dressings. V20 said the wound care team does all the treatments. V20 said no CNA reported that R13 needs a new dressing or that the dressing was removed. V20 said if she was made aware that a dressing was removed, she would look at the wound and notify the wound care team. R13's Medication Review Report notes order initiated on 6/22/22 for left foot to have foam dressing applied three times weekly and as needed. An order initiated on 4/20/22 notes low air loss mattress. R13's Wound Care record dated 7/14/22 notes pressure redistribution mattress per facility protocol and offload heels per facility protocol. R13's care plan for risk for skin breakdown initiated 4/20/22 notes elevate heels off bed. Progress Note for R13 dated 6/22/22 notes heels are being offloaded while in bed. R13's weight on 7/1/22 is documented to be 126.2 pounds. C. On 7/14/22 at 11:14AM the Surveyor observed R19 in her bed on an air mattress the pump observed to be set to normal pressure and below 80. R19's progress notes dated 6/25/22 note she has an open area to the sacrum, low air loss mattress in place. R19's Wound Assessment Detail Report notes she had a Stage 2 identified on 6/25/22. R19's weight on 7/4/22 notes 150 pounds The facility provided an Operation Manual for the use of the pressure reduction mattresses used in the facility. On page 7 operating instructions note step 6: Determine the patient's weight and set the control knob to that weight setting on the control unit. The facility policy for Pressure Injury and Skin Condition Assessment revised 1/17/18 states: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. Caregivers are responsible for promptly notifying the charge nurse of skin breakdown. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. Dressings which are applied to pressure ulcers, skin tears, wounds, [CONDITION(S)] or incisions shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. The facility policy for Pressure Ulcer Prevention revised 1/15/18 states as follows: Pressure reducing mattresses are used for all residents unless otherwise indicated. Specialty mattress such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents with multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes, and malleoli as indicated. R8 R8 was admitted on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal data set section G (functional status) documents: R8 is totally dependence with two person assist with bed mobility. V4 (R8's family) said, the facility is not able to take care of R8's wound. R8 is not being turned and repositioned every two hours. R8 was left in feces over night from her waist down to her feet which has caused R8 wound to get worst. V4 showed a picture of R8 lying in bed similar to R8's current bed/room covered in brown liquefied stool from R8's waist to feet. On 7/15/22 at 3:11pm, V57 (unit manager) was observed repositioning R8 by removing the wedge from under R8's left upper body, pillows from in between knees, towel roll from hand and on the side of R8's neck. V57 walked to R8's right side of the bed, pulled the sheet to shift R8 body from the right facing the window to the left facing the wall, place the wedge behind R8's right upper body, replace the pillow and towel rolls. V57 repositioned R8 by herself. On 7/22/22 at 10:57am, V30 (wound doctor) said, R8 had a decline of the superficial wound, incontinence can make R8's sacrum wound get worst. On 7/28/22 at 4:19pm, V4 (R8's family) said, I saw R8 soiled with urine on the bed pad and R8 was wearing a diaper. On 7/29/22 at 2:03pm, V4 (don) said, R8 had some loose stool, V4 showed picture. I could not tell how long R8 had been in stool based on the picture On 7/29/22 at 3:30pm, V60 (CNA) said, I saw R8 soiled in feces. R8 had feces on her waist, legs and feet. R8's gown and sheets were covered in feces on 6/18/22. I found R8 covered in feces twice (second date unknown). I had to clean R8 up from being covered in feces twice. Both times, I saw R8's soiled/covered in bowel movement. The bowel movement was a mixture of fresh watery stool and old pasty dried stool. R8 had a wet disposal pad/chuck under her buttock once or twice due to the Foley leaking. On 8/3/22 3:04 pm, V25 (wound nurse) said, R8 was a risk for skin breakdown related to turning and repositioning. R8 must be completely lifted off the bed with transfers/repositioning. R8 is a two person assisted bed mobility. If one person reposition/turn R8 we cannot ensure R8 won't have any friction for the pulling of the sheets. Friction causes skin breakdown from skin rubbing up against items. R8 should be lifted instead of pulled. Pulling on the sheets can lead to skin break down. I don't see any interventions on R8 care plan for the MASD. On 8/3/22 at 4:27pm, V25 (wound nurse) said, the V30 (wound doctor) put the calcium alginate order in place just in case if R8 had drainage. It was not on the TAR. It should have been as a PRN. On 8/4/22 at 11:37am, V30 (wound doctor) said, R8 was very incontinent of stool. R8 had MASD which was an excoriation caused by R8's stool and urine. Intervention should be put in place for skin alterations and changed if they are not working. I wrote the calcium alginate for moderate to serious drainage. The order should had been put on the TAR. Wound assessment dated [DATE] documents: R8 had a facility acquired sacrum wound that was noted with redness during incontinence care. Wound type: Moisture Associated [CONDITION(S)] (MASD) measuring 6.00 x 9.00 x 0.00 (L x W x D). Care plan dated 6/15/22 documents: MASD -no interventions. Wound assessment dated [DATE] documents: Wound type: facility acquired sacrum moisture associated [CONDITION(S)] (MASD) measuring 0.00 x 0.00 x 0.00 (L x W x D). Wound doctor note dates 6/27/22 documents: Consult for sacral MASD Irritant contact [CONDITION(S)] due to friction or contact with body fluids. Wound assessment dated [DATE] documents: Wound type: facility acquired sacrum moisture associated [CONDITION(S)] (MASD) measuring 10.50 x 11.50 x 0.10 (L x W x D). R8 noted with change in wound during care. Wound assessment dated ,d+[DATE] /22 documents: Wound type: facility acquired sacrum moisture associated [CONDITION(S)] (MASD) measuring 10.00 x 6.00 x 0.10 (L x W x D). Incontinent of bowel and bladder with incontinent care provided. Wound doctor note dated 6/30/22 document: R8's sacral ulcer was worse, and classification has been changed to pressure. R8's sacral wound is a stage 3 pressure injury/pressure ulcer, deteriorating status, with a moderate amount of drainage measuring 10 cm length x 6 cm width x 0.1 cm depth. Cover with alginate. Wound assessment dated [DATE] documents: Wound type: facility acquired sacrum moisture associated [CONDITION(S)] (MASD) measuring 8.20 x 6.50 x 0.10 (L x W x D). R8 wound noted with increased necrotic tissue light serous drainage present. R8 being sent to the hospital. Nurse Practitioner note dated 7/11/22 documents: R8 was admitted to hospital (7/6/2022-7/8/2022) due to fever 102 as well as worsening sacral ulcer. [MEDICATION(S)]-resistant enterococci (VRE) in superficial wound which was attributed to colonized. Treatment administration record dated 7/1/22 -7/31/22 did not document alginate as a treatment.

Based on interview and record review, the facility failed to implement dietary recommendation to prevent unplanned weight loss for 2 of 3 (R30 and R1) reviewed for unplanned weight loss prevention. This failure resulted in R30 having a 12% weight loss in a 30-day period, and R1 having an insidious weight loss of 16.9 pounds over a six-month time frame. Findings include: R30 R30's discharge hospital paperwork printed 3/4/22 documents: diet puree. 1:1 feed. Dietary note dated 4/12/22 documents: Informed of decrease appetite. Food intake varies 25-50% meal. R30 with new wounds. At high risk for malnutrition related to inadequate nutrient intake. Plan: recommend increasing liquid protein 30ml three times a day, house supplement 120ml three times a day, consider appetite stimulate, fortified potatoes lunch and dinner, weekly weight for four weeks. R30's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Regular diet end 4/19/22. Liquid Protein three times a day for wound healing, med pass (2.0) 120ml /supplement and [MEDICATION(S)] 5ml order 4/26/22 Speech Therapy Plan of Care dated 4/19/22 document: R30 was recommended to be on puree/thin diet texture during 3/2/22 hospitalization with 1:1 feeding assistance. Previous weight: 5/5/22 - 150 pounds 4/4/22 - 170.4 pounds - change over 30 days [Comparison weight 4/4/22 170.4, -12% 20.4lbs] 3/8/22 - 171.2 pounds On 7/21/22 at 12:19pm, V58 (dietitian) said, R30 was supposed to be on a pureed diet, I must have missed it in the hospital papers. On 8/4/11 at 4:51pm, V67 (speech language pathologist) said, R30 had moderate to severe swallowing impairment. On 8/10/22 at 3:34pm, V1 (DON) said, R30 dietary recommendation written on 4/12/22 wasn't implemented until 4/26/22. Hospital discharge paperwork is reviewed for continuity of care. R30 was not started on a pureed diet as prescribed from the hospital and week weights were not done. On 8/11/22 at 12:14pm, V69 (MDS coordinator) said, R30 received feeding assistance 7 days in March and April. On 8/15/22 at 4:30pm, V58 (Dietitian) said, I expected my interventions to be implemented. If my recommendations were offered/implemented, I would have been able to see if they made a difference such as decrease hydration, promote wound healing and increase calories to promote weight gain/stability. Eating point of care charting dated 3/1/22- 3/31/22 document: R30 received feeding assistant on 3/1 (dinner), 3/14 (dinner) 3/20 (dinner), 3/23 (breakfast), 3/24 (dinner), 3/26 (breakfast/lunch) and 3/28 (dinner). Eating point of care charting dated 4/1/22- 4/30/22 document: R30 received feeding assistant on 4/8 (dinner), 4/17 (dinner), 4/25 (lunch/dinner), 4/27 (dinner), 4/28 (dinner) and 4/29 (breakfast/lunch). Weight Assessment and Intervention undated documents: The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Interventions for undesirable weight loss shall be based on careful consideration of the following: chewing and swallowing abnormalities and the need for diet modifications. Severe weight loss greater than 5% in 1 month. R1 Dietary note dated 5/23/22 document current weight indicates significant weight loss in 1, 3, 6 months despite of nutrition intervention. Weight loss due to variable appetite. Food intake 25%-75% of meal. Weight loss unplanned and unavoidable. To halt further weight loss, recommend increasing med 120ml to TID (three times a day) and double potion at breakfast and weekly weight times four weeks R11's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Current weight 7/28/22-164.4 pounds Previous weight 6/3/22 - 167 pounds 5/24/22 -164.4 pounds 5/17/22 -162.6 pounds 5/5/22- 163 pounds [Comparison weight 174.4 lbs. -6.5% -11.4lbs] 4/4/22 - 174.4 pounds 3/8/22 - 170.2 pounds [Comparison weight 2/4/22 181.3 pounds, -6.1% -11.1 lbs] 2/4/22 -181.3 pounds On 7/21/22 at 12:19pm, V58 (Dietitian) said, R1 had an ordered for double portions all meals but R1 refused to eat double all meals so I made it double potion for one meal. Sometimes a lot of food on the plate can be overwhelming. On 8/10/22 at 3:34pm, V1 (DON) said, R1's health shake was not increased to three times a day and double portion at breakfast wasn't added as recommended. On 8/15/22 at 4:30pm, V58 (Dietitian) said, I expected my interventions to be implemented. If my recommendations were offered/implemented. R1's health shake was supposed to be on three time a day. I order double portion at breakfast to see if R1 would eat then I was going to gradually increase it but the meal shakes were not changed or the double implemented. Weight Assessment and Intervention undated documents: The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Interventions for undesirable weight loss shall be based on careful consideration of the following: use of supplements. Severe weight loss greater than 10% in 6 months.

Based on observations, interviews, and records reviewed the facility failed to follow their pain management program to ensure that staff report pain and treat verbalizations and symptoms of pain for 1 residents (R2) of 3 reviewed for pain. This failure resulted in R2 screaming and reporting pain in her left leg during care. Findings include: A.R2 is [AGE] years old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Cognitive score is intact. On 7/14/22 at 12:25PM V29, Certified Nursing Aid (CNA), and V14, CNA, entered R2's room to provide care. While V29 and V14 were providing care to R2 and attempting to assist R2 to turn onto her right side, R2 was crying and rubbing at her left thigh. R2 was sobbing loudly saying this leg indicating pain in her leg. V14 and V29 continued with care and turned R2 onto her right side to change her brief and R2 was audibly crying. V14 and V29 completed incontinent care and provided R2 with clean linens. On 7/14/22 at 12:52PM V21, Licensed Practical Nurse (LPN), said R2 reported no complaints to her today. V21 said she did not give R2 any as needed pain medications. V21 said she gave R2 her morning medications. V21 said she did vitals on R2 this morning. V21 said full vitals include temperature, pulse, blood pressure, and respirations. V21 said she did not perform any assessment on R2 today. V21 said no one has reported concerns to her regarding R2. On 7/21/22 at 3:03PM V1, Director of Nursing (DON), said if a resident shows pain during care, then the nurse should take care of it and give the resident whatever the doctor has ordered. V1 said the CNA should report pain immediately to the nurse. V1 said if a resident reports pain during care the CNA should ask the resident if they can continue with care or if they want medicine before they continue. On 7/22/22 at 9:59AM V29 said residents show pain by not eating, not wanting to get up, or they verbally report pain. V29 said if during care the resident reports pain then she would finish providing care and then report to the nurse, once care has been completed. Medication Review Report for R2 notes order on 6/28/22 for left knee X-Ray for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As needed pain medications include Acetaminophen and [MEDICATION(S)], both every 6 hours when needed. V1, provided the surveyor with the X-Ray results for left knee was performed for R2 on 7/14/22, after the surveyor requested the results of the X-ray ordered on 6/28/22. R2's care plan initiated on 5/16/22 notes R2 has acute on chronic pain related to bilateral knee Arthritis. Potential for further signs/symptoms of pain and discomfort related to Gout, Polymyalgia Rheumatica, [CONDITION(S)], and bilateral lower extremity muscle spasms. Interventions include administer analgesia as ordered. Monitor/ record/ report to nurse any signs/symptoms of non-verbal pain including vocalizations, face (sad, crying, grimacing), and body (tense). Review of R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain scale for R2 on 7/14/22 day shift notes 0 for no pain. Acetaminophen and [MEDICATION(S)] tablets are not signed as administered. The facility Pain Management Program revised on 7/16/18 notes: The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determined the present of pain. Assessment of non-verbal residents for signs and symptoms of pain. Pain to be considered the 5th vital sign, along with temperature, pulse, respiration, and blood pressure. All care givers are instructed to report the resident's or family's report of pain or discomfort.

Based on interview and record review, the facility failed to do a comprehensive assessment following a fall for one of three residents (R1) reviewed comprehensive physical assessment. This failure resulted in a delay of identification of the left femoral neck fracture and delay in care of the fracture for R1. Findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status score 12/15. A score of 12 indicates cognitively intact. R1's progress note date 10/28/21 at 13:30 documents: CNA {Certified Nursing Assistant} alerted nurse that resident was on the floor, upon entry to room resident was noted lying on the floor in between both beds on her back, alert and denies pain. On 11/5/21 at 3:02 PM, V3 (Nurse) said she asked R1 what happened but R1 appeared to be in shock and was just looking at V3. V3 said she lifted R1's arms and raised both of R1's legs with no pain noted from R1. V3 said she did not ask R1 again what happened or perform any additional assessments. On 11/10/21 at 2:24 PM, V4 (CNA) said after she assisted R1 back to bed she put a gown on R1 and went to assist other residents on her unit. V4 said she did not see R1 again that shift. On 11/16/21 at 4:07 PM, V12 (CNA) said she was assigned to R1 on 10/28/21 evening shift (3-11 pm). V12 said she saw R1 was shaking in her bed and did not appear be herself. V12 said she told the nurse, who informed V12 that R1 was going to the hospital and they were aware of R1's concerns/fall. On 11/17/21 at 2:25 PM, V16 (Restorative Nurse) said R1 would not be able to complete lower range of motion due to contractures and would need to be sent out for evaluation immediately after a fall. On 11/5/21 at 1:45 PM, V14 (R1's family) said she spoke to R1 following the fall on 10/28/21 around 400pm. V14 said when she spoke to R1, R1 was complaining of chest pain and hip pain, and V14 had to call back the facility to ask to have R1 transferred to the hospital. On 11/5/21 at 3:56 PM, V5 (Unit Manager) said she received a call from V14 (R1's family) reporting that R1 was having knee, elbow and chest pain. V5 said she went to see R1 who reported she hurt all over. V5 said she did not ask R1 about the fall or how she fell because that is the responsibility of the nurse assigned. V5 said that V3 (Nurse) told V5 that R1 was not able to say what happened at time of fall. V5 said V3 raised R1's bilateral lower legs by her feet with no complaints of pain. V5 said V3 did not do any further assessments for R1. On 11/17/21 at 1:24 PM, V13 (Medical Doctor/MD) said if a resident is complaining of chest pain, they should be sent out 911 for evaluation. R1's progress note dated 10/28/21 at 16:23 documents: orders received to send R1 out related to fall and new onset chest, elbow and knee pain. R1's progress note dated 10/28/21 at 16:48 documents: R1 was noted with complaints of pain to left arm and left leg. Tylenol 650 mg given for pain. R1's hospital record dated 10/28/21 at 17:48 documents: R1 arrival at hospital. R1's pain was documented as a 6/10. Under X-Ray results documents: There is a subcapital femoral neck fracture with angulation of the fracture superiorly. Under impression: left femoral neck fracture.

Based on interview and record review, the facility failed to provide safe bed mobility while providing direct resident care for one (R1) of three residents reviewed for bed mobility. This failure resulted in R1 sustaining a fall from the bed while receiving care by facility staff and R1 sustaining a left femoral neck fracture. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including bacteremia, reduced mobility, calorie malnutrition, [CONDITION(S)], [CONDITION(S)], dysphagia and chronic pain syndrome. R1's Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status score 12/15. A score of 12 indicates cognitively intact. Under functional status for bed mobility - how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture documents a score of 3 under self-performance. A score of 3 indicates extensive assistance - resident involved in activity, staff provide weight bearing support. Under support - a score of 2 which indicates one-person physical assist. R1's risk management incident witness dated 10/28/21 documents: V4 (Certified Nursing Assistant/CNA) stated that during resident's bed bath, resident had a big bowel movement. Next V4 went to wet a towel and noticed resident had rolled out of bed where she landed in an almost sitting position. V4 stated the resident's leg went first, adding, resident heel protectors were on at that time, resident then fell sideways with her back against the bed. At that point CNA stated that she had to lower her to the floor were the side rail caught resident's right shoulder. Resident was on the floor in between both beds, on her right side. CNA said the bed was fairly high but not in the highest position. In addition, CNA stated she did not see the resident hit her head. On 11/5/21 at 1:45 PM, V14 (R1's family) said she spoke to R1 following the fall on 10/28/21 around 4:00 PM. V14 said R1 said V4 (CNA) rolled R1 on her right side and left her on her side for a long time because V4 went into the bathroom to talk to her boyfriend on the phone. R1 rolled out of bed. On 11/5/21 302PM, V3 (Nurse) said that V4 (CNA) reported that she was giving a bed bath to R1. When V4 rolled R1 to her back side, R1 began to have a large bowel movement and V4 went to the bathroom to wet a towel and when she turned back to the resident, R1 was on the floor. V3 said she did not recall on bowel movement on the resident or odor of bowel movement in the room. On 11/5/21 at 3:56 PM, V5 (Unit Manager) said she asked V4 (CNA) what happened with R1 on day of the fall. V4 said she was providing ADL (Activities of Daily Living) care to R1 when R1 started to have a bowel movement. V5 said V4 (CNA) reported that she went to wet a towel in the bathroom to clean the bowel movement and when she returned to R1, R1 was on the floor in sitting position. V4 reported she lowered R1 to the floor and got the nurse. On 11/16/21 at 4:07 PM, V12 (CNA), who was assigned to R1 on 10/28/21 evening shift (3-11pm), said R1 was shaking and did not appear to be herself. V12 (CNA) said that R1 reported that V4 (CNA) was on the phone arguing with her boyfriend and dropped her. On 11/17/21 at 2:25 PM, V16 (Restorative Nurse) said R1 required one person for bed mobility for safety. R1 would be able to stay on her side when turned and not roll. R1 was not considered a fall risk and did not have any previous falls. On 11/10/21 at 2:24 PM, V4 (CNA) said she was providing R1 with a bed bath. R1 was on her right side when R1 began to have a large bowel movement. V4 said she assisted R1 to her back to assist with cleaning her and when she turned her back to her right side, R1's right foot began to slide out of bed and R1 slid to the floor. V4 said she was unable to stop the resident from slipping out of the bed. V4 said R1 had bowel movement on her and during the transfer. V4 denied ever leaving the resident unattended or being on the phone during care. Facility Fall Prevention Program revised 11-21-17 documents: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing their risk for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Residents who require staff assistance will not be left alone after being assisted to bathe, shower or toilet.

Based on interview and record review, the facility failed to consistently and accurately assess, monitor, and implement interventions such as: laboratory/diagnostic testing, weight monitoring, cardiology consultations, and medications for one resident (R4) out of three reviewed for receiving the needed care and services related to the management of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R4 not receiving medications to treat CHF, no laboratory/diagnostic testing to the monitor disease process, and an unmonitored weight gain of 41.4 pounds between 2/5/21 and 6/14/21. R4 suffered a respiratory/[CONDITION(S)] on 6/23/2021 and expiring at the hospital. Findings include: Review of the medical record documents R4 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/2021 at 1:30pm, V6 (Respiratory Therapist) stated that V6 is not familiar with R4. V6 stated that R4 was not on respiratory therapy's caseload. On 8/11/2021 at 1:00pm, V2 (Director of Nursing/DON) stated that staff do not review physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated that the physician should also be ordering laboratory testing, not just noting in progress notes. V2 stated that residents are weighed weekly x 4 upon admission to this facility. V2 stated that all residents are weighed monthly by the restorative aide or the CNA (Certified Nurse Aide). V2 stated that the weight results are given to the nurse, restorative nurse, or unit manager to enter into the resident's electronic medical record. V2 stated that the restorative nurse, dietitian, and interdisciplinary team look at resident weights. V2 stated that when entering resident's weight in electronic medical record, the nurse should compare to previous weight, will do re-weigh if change/discrepancy in weight (+/-). V2 stated that the re-weigh result will be given to nurse to enter into the resident's chart. V2 stated that the interdisciplinary team reviews newly admitted resident's weights and residents with weight discrepancy. V2 stated that V19 (Consultant Pharmacist) reviews each resident's medications monthly. V2 stated that V2 has not seen the pharmacist come to this facility or received any recommendations from pharmacist regarding R4 since V2 started at this facility in March 2021. V2 stated that the dietitian follows all residents monthly at facility. V2 stated that the dietitian is at this facility weekly. On 8/11/2021 at 2:15pm, V8 (Restorative Nurse) stated V8 started working at this facility in July 2021. V8 stated that the restorative aides weigh newly admitted residents weekly and all residents monthly unless there is a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V8 stated that if a resident has a 10 pound weight loss or gain, V8 will have staff re-weigh the resident to confirm the weight, and will discuss with the resident's nurse and dietitian. V8 stated that V8 is part of the interdisciplinary team that meets to discuss residents and their diagnoses. V8 stated that the aides will use the same measurement device (standing scale or mechanical lift device) for a resident to keep weights as accurate as possible. On 8/12/2021 at 9:55am, V22 (Licensed Practical Nurse/LPN) stated that V22 was familiar with R4. V22 stated that R4 got up at 5:30am and was already dressed prior to the start of V22's day shift. V22 stated that V22 was not able to assess R4 for any [CONDITION(S)] (swelling) in legs/feet because R4 had socks and shoes on. On 8/12/2021 at 12:25pm, V19 (Consultant Pharmacist) stated that V19 reviews each resident's medications and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . V19 stated that if a resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V19 stated that V19 did not note that R4 was on any medications for diabetes. After reviewing R4's medication, V19 stated that R4 was receiving insulin therapy for diabetes. V19 stated that V19 did not note V18's (physician covering for V17/attending physician) progress notes noting R4 needed to start a low dose ACE inhibitor medication. V19 stated that V19 would have recommended for R4 to start on [MEDICATION(S)] based on diagnoses. On 8/13/2021 at 1:15pm, V16 (Registered Dietitian/RD) stated that V16 comes to this facility weekly to follow high risk residents. V16 stated that residents with significant weight gain would be considered high risk residents. V16 stated that V16 runs a weight report weekly which documents all residents' weights. V16 stated that V16 reviews the monthly weights for any changes, and if planned or unplanned. V16 stated that V16 last documented on R4 on 5/20/21. V16 stated that V16 noted R4 had a significant weight gain and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V16 stated that V16 asked the nurse if R4 had any changes in meal intake or any fluid retention. V16 stated that R4's oral intake was good and no report of swelling in legs. V16 stated that V16 attributed R4's weight gain to excess calories. V16 stated that V16 recommended a no added salt diet and to re-weigh R4 to confirm weight. On 8/13/2021 at 1:20pm, V17 (Attending Physician) stated that the documentation noting cardiology services needed for follow-up is done to maintain continuity of R4's care. V17 stated that V24 (Cardiology Nurse Practitioner) had seen R4 months prior and follow-up was not needed. V17 stated that V18 (physician covering for V17) recommended R4 should start an ACE inhibitor medication, but cardiology noted R4 stable on current medication regimen and did not need to start an ACE inhibitor medication. V17 stated that V17 believes V18 was made aware of R4's weight gain. When questioned regarding the documentation V17 noted in progress notes on 1/6/21 for laboratory testing weekly for BNP levels and not ordered or performed, V17 stated Oh. V17 stated that V17 was not aware that laboratory testing ordered on 5/15/21 to be done every 15 days was not done. V17 stated that R4 was receiving a strong diuretic. V17 stated that respiratory therapy was monitoring R4. Review of R4's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's medical record notes R4 had been receiving a no added salt diet since admission to this facility on 11/30/2018. V16 last saw R4 on 3/18/2021. Review of R4's physician documentation notes the following: On 1/6/21, V17 (Attending Physician) noted Continue to monitor R4 clinically and trend R4's blood work as appropriate. CHF with ejection fraction 25% - 30%; Continue current medications, weekly BNP (brain natriuretic peptide - protein made in the heart, the level produced increases as heart failure worsens). On 4/21/21, V18 (physician covering for V17) noted R4 is at this time not on ACE (angiotensin-converting enzyme) inhibitor medication (medication that helps relax veins and arteries to lower blood pressure by preventing an enzyme from being produced that narrows blood vessels which causes the heart to work harder), we will start R4 on low dose ACE inhibitor medication given history of CHF. On 4/26/21, V18 (physician covering for V17) noted R4 is not on guideline directed medical therapy at this time (for CHF). R4 is not on ACE inhibitor, no recent echocardiogram on file. We will refer R4 to cardiology services for further evaluation. Will consult Cardiology on R4 and get records for echocardiogram. On 5/4/21, V18 noted R4 needs to follow up with cardiologist, referral already made. R4 will need to follow up closely with cardiologist as well as likely will need a repeat echocardiogram since last echocardiogram was many months ago. On 5/11/21, V18 noted R4 with heart failure with reduced ejection fraction. R4 is not on ACE inhibitor or ARB (angiotensin II receptor blocker, medication similar to an ACE inhibitor). Cardiologist needs to follow up. Referral is made. Consult pending. Nursing communication done to see a cardiologist. Repeat echocardiogram is also needed. At this time, we will do a set of repeat laboratory tests to monitor for advancing kidney disease. Continue to monitor R4 closely however. On 5/17, V18 noted Kidney disease, creatinine level is stable. At this time, continue to monitor laboratory tests every 2 weeks. Avoid nephrotoxins. Heart failure with reduced ejection fraction, cardiology nurse practitioner needs to follow R4. Referral already made. Consult pending. Review of R4's medical record notes R4 was last seen by V24 (Cardiology Nurse Practitioner) on 1/12/2021. V24 noted R4 with 3+ pitting [CONDITION(S)] (swelling) in both lower extremities, left more than right; consider initiating diuretics. Monitor intake and output, daily weights. V24 recommended initiating a diuretic medication, monitoring intake and output, and daily weights since 6/29/2020. There is no documentation found in R4's medical record noting intake and output monitored, daily weights, or diuretic medication initiated for R4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation found in R4's medical record by cardiology services noting R4 did not need to start an ACE inhibitor medication or that cardiology services were made aware of the several requests by V18 for R4 to be seen. Review of R4's respiratory assessment, dated 4/5/21, notes follow-up assessment is needed for R4. On 5/5/21, the respiratory assessment notes R4's heart rate, oxygen saturation level, and respirations. There is no documentation noting R4 was assessed by respiratory therapy on 5/5/21. There is no further documentation in R4's medical record noting respiratory therapy continue to follow R4's care. Review of R4's weight documentation notes the following: On 2/5/21, R4's weight was 206.8 pounds. On 3/10/21, R4's weight was 217.6 pounds; an increase of 4.9% in one month. On 4/5/21, R4's weight was 216.4 pounds. On 5/6/21, R4's weight was 235.8 pounds; an increase of 8.23% in one month. On 6/14/21, R4's weight was 248.2 pounds; an increase of 4.9% in one month. R4's weight increased 12.33% in 3 months (March to June). R4's weight increased 41.4 pounds (16.68%) between February and June. There is no documentation found in R4's medical record noting R4's weights were retaken to confirm weight or that V17 (Attending Physician) was notified of weight gain. Review of R4's medical record does not note any documentation that R4's BNP levels were monitored in 2021. This facility last ordered a BNP level for R4 in 2018. There is no documentation found noting R4's laboratory testing to monitor kidney function ordered to be done on 5/15/21 were repeated every 15 days. On 5/17/21, R4's BUN (Blood Urea [MEDICATION(S)]) level was 34 (normal range is 7-23) and creatinine level was 1.7 (normal range is 0.4-1.6). R4's previous laboratory results, dated 4/7/21, noted R4's BUN 26 and creatinine 1.5. Review of R4's care plan notes R4 has [CONDITION(S)]. Interventions identified include to give cardiac medication as ordered, monitor/document/report as needed any signs/symptoms of CHF: dependent [CONDITION(S)] of legs and feet, shortness of breath with exertion, weakness, weight gain, lethargy, and disorientation, and oxygen via nasal cannula. Review of R4's death certificate, dated 6/23/2021, notes primary cause of death respiratory arrest. Review of WebMD.com notes testing BNP levels is one of the most sensitive ways to show how well a person is doing on heart failure treatment. An echocardiogram is a graphic outline of a person's heart's movement. It provides pictures of the heart valves and chambers. An echocardiogram is used to check the overall health of a person's heart, follow the progress of heart disease, and see how well heart treatment is working. Angiotensin II receptor blockers (ARBs) have similar effects as ACE inhibitors but work by a different mechanism. These drugs block the effect of angiotensin II, a chemical that narrows blood vessels. By doing so, they help widen blood vessels to allow blood to flow more easily. Review of this facility's weight assessment and intervention policy, revised September 2008, notes any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Review of this facility's weight change investigation policy, revised 07/2014, notes a weight change investigation will be initiated for a significant weight change of 7.5% in 3 months or an insidious weight change of 5 pounds or more in two consecutive months. Once the weight change investigation is completed, the dietitian and the physician will be notified for interventions.

Based on interview and record review, the facility failed to implement a pressure ulcer intervention to prevent the development of a facility acquired pressure ulcer and provide the necessary care and services to promote healing and prevent infection for one resident (R6) out of 5 residents reviewed for pressure ulcers in a sample of 12. This failure resulted in R6 requiring surgical intervention for a stage 4 infected sacral pressure ulcer with exposed bone. R6 also required long term intravenous antibiotic therapy. Findings include: Review of the medical record notes R6 was admitted to this facility on 1/6/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/12/21 at 2:00pm, V12 (Wound Care Nurse) stated that V12 started working at this facility a few months ago and is not familiar with R6. V12 stated that wound treatments are changed immediately if a resident's wound is deteriorating, because the current treatment is not working. V12 stated that if the air mattress is not plugged in/turned on, there will be no air flow. V12 stated that if air is not flowing through the low air loss mattress, the mattress will deflate and the resident will be lying on the metal frame and this would cause wound deterioration. V12 stated that residents should not be on a deflated mattress for any period of time. V12 stated that staff would be able to notice if an air mattress was deflated and should [MEDICATION(S)] immediately to remove resident from the bed. V12 stated that if pressure wound was deteriorating, V12 would recommend sending resident to hospital for further evaluation and treatment. V12 stated that the treatment order is up to the physician, but V12 does have a voice and would have recommended a different enzymatic medication instead of wet to dry dressings. V12 stated that R1, R7, R8, and R9's pressure ulcers are healing with the current treatment plan in place. Review of R6's MDS (Minimum Data Set), dated 1/13/2021, notes R6 requires extensive assistance from two staff members for bed mobility, transfers, and hygiene. R6 is totally dependent on one staff member for toileting. Review of R6's admission note, dated 1/6/2021, notes R6 is alert and oriented to self, time, place and circumstances. R6's skin is clear and without any wounds noted. Review of R6's wound care documentation notes: On 1/7/21, upon skin assessment R6 was noted with an unstageable wound to the right coccyx with measurement of 2.6cm (centimeters) x 1cm, 70% slough (yellow dead tissue) and 30% pink tissue. On 1/13/21 weekly wound note: coccyx - unstageable wound, measuring 2cm x 1.7cm, no drainage noted, 100% eschar (black dead tissue). On 1/21/21 wound note: coccyx wound unstageable, measuring 2.5cm x 2cm, light drainage noted, thick adherent devitalized necrotic tissue 100%. Wound progress: deteriorated. R6 also noted with a stage 2 pressure wound to right buttock, measuring 0.5cm x 0.5cm x 0.1cm, light drainage noted. On 1/27/21 wound note: stage 4 pressure wound to coccyx, measuring 3cm x 3cm x 2.5cm. Undermining: 1cm at 3 o'clock, drainage moderate, thick adherent devitalized necrotic tissue: 100%. Wound progress: deteriorated. On 1/28/21 wound note: upon doing treatment this morning, R6 was noted on an uninflated air mattress. R6 stated R6 had been laying like that all night. Upon wound inspection, wound had deteriorated and periwound was macerated, broken down and bleeding. On 1/30/21 wound note: upon performing wound treatment deterioration noted to wound. wound 8cm, undermining noted at 6 o'clock along with an increase in wound size with moderate purulent drainage. Extended periwound deep tissue injury and necrotic wound bed noted. Wound physician was notified and requested to perform a telemedicine visit due to R6's deteriorating wound. Physician examined wound and requested a culture of wound and a full [CONDITION(S)] work up to be done. On 1/30/21 R6 complaining of pain at wound site. Position change done every 2 hours - right to left as tolerated. Stated relief. On 2/1/21 at 7:50am, R6 stated R6 is uncomfortable and in pain related to wound in buttock. Vital signs assessed: blood pressure 170/102, heart rate 74 beats/minute, temperature 103 degrees Fahrenheit, respirations 18/minute, and oxygen saturation level 89%. Oxygen at 2 liters/minute per nasal cannula applied and R6 was repositioned to left side to ease pressure on R6's buttock. On 2/1/21 at 9:19am wound note: upon rounds R6 noted feeling warm to touch, vital signs: temperature 104.5 degrees. On 2/1/21 at 10:32am, R6 reassessed, continues to moan related to pain in R6's buttock, was repositioned. On 2/2/21 wound note: Stage 4 pressure wound to coccyx, measuring 5.2cm x 12cm x 3.7cm. Undermining: 9cm at 6 o'clock, drainage: heavy purulent. Thick adherent devitalized necrotic tissue: 90%, 10% bone exposed. Wound Progress: deteriorated. Wound care physician recommended that R6 should be sent out for wound infection. Review of R6's hospital record, dated 2/2/2021, notes on 2/5/21, R6 had surgical excision of sacral pressure ulcer and bone biopsy. R6's sacral pressure ulcer measured 13cm x 13cm with necrotic tissue and necrotic bone suggestive of sacral [CONDITION(S)]. During surgery, some of R6's sacral bone had to be removed as it was in multiple pieces and fragments. Infectious disease physician noted unstageable sacral pressure ulcer with foul smelling drainage, R6 cries out when wound examined. R6 will need prolonged (6 weeks) intravenous antibiotics for sacral [CONDITION(S)]. Review of R6's care plan, dated 1/21/2021, notes R6 has a stage 4 pressure ulcer to the coccyx related to immobility. Interventions identified include: administer treatments as ordered and monitor for effectiveness, educate R6/family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, inform R6/family/caregivers of any new area of skin breakdown, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of this facility's pressure injury treatment guidelines, dated 07/2021, notes to implement prevention protocol according to resident needs. Provide appropriate pressure redistribution devices.

Based on interview and record review the facility failed to follow its Medication and Treatment Orders policy and notify the Nurse Practitioner of 2 open wound sites and failed to follow its Prevention of Pressure Ulcer policy by not assessing and identifying an infected sacral wound for 1 (R1) of 3 residents reviewed for pressure ulcers and pressure ulcer prevention. This failure resulted in R1 receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1 admitted on [DATE]. R1's skin wound evaluation with an effective date of 4/22/21 documented 3 sites: sacral, lateral left leg and right hip. All wounds were classified as unstageable (adhered slough and eschar). Review of Treatment Administration Record (TAR) for April 2021 and May 2021 documented treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment order was to cleanse with normal saline solution/wound cleanser skin prep to periwound. Apply honey; cover with dry protective dressing daily and as needed. Weekly Wound Assessment Forms for all three sites were reviewed and noted weekly assessments dated 4/22/21, 4/28/21 and 5/5/21. On 5/12/21 weekly wound assessment form stated: Refused, unable to assess due to health. Last documented skin assessment was on 5/5/21, with sacrum documentation as: wound size (2.0 x 1.5) with wound etiology of unstageable, wound bed as 100% slough, periwound intact, and no drainage and wound status recorded as declining. R1 was transferred to local hospital on 5/16/21 for respiratory distress. Hospital records document CT of abdominal pelvis done on 5/16/21 shows skin breakdown overlying the sacrum with probable ostial lysis of the sacrum, concern for sacral decubitus ulcer with underlying [CONDITION(S)]. Correlate with physical exam. R1 received antibiotic treatment in the local hospital. On 5/21/21 at 12:30pm V8 (Wound Nurse Coordinator) stated, We document in the Treatment Administration Record (TAR). I forgot the treatment order for left leg and right hip, but I was doing the treatment every time I did the sacral wound. I was just overwhelmed, and I forgot to enter the treatment order. The majority of the time, I was the one seeing R1's wounds.I do understand that staff don't have anything to look at TAR on what treatment to use, but I do tell them what the treatments are. On 5/25/21, V8 stated, Sacrum was 100% (yellow, brownish and no sign of infection) unstageable. There is no other attempt to do a thorough reassessment for the wound after R1 refused on 5/12/21. R1 went out to hospital; that is why there is no follow up documentation. May 5, 2021 was the last time I did weekly wound assessments with R1, but I assess every time I do the daily treatment. On 5/21/21 at 1:30pm, V9 (Nurse Practitioner) stated, I know of one site because during my visit, I observed the nurse changing the treatment on the sacral wound. I honestly cannot remember if there were any additional sites. They might have informed me, but I cannot remember everything from one month ago. I am okay with whatever the wound nurse wants to put on R1's wound as the treatment order, because they are the experts and they do wounds all the time. I trust staff and the wound care nurse because they are the ones that do the treatment and know what would work and promote wound healing. There should be a written order for treatments for each site so other nurses would know the game plan for each specific wound site to promote wound healing. On 5/25/21 at 3:30pm, V1 (Director of Nursing) stated, We need to have treatments for each site because each site needs to be monitored differently. Staff would not know what treatment is for each wound site if the order is not entered. Weekly thorough assessment is required. Also as they change the dressing, they assess the wound. Medication and Treatment Orders (version 2.0) policy documents: Orders for medications and treatments will be consistent with the principles of safe and effective order writing. Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. All drugs and biological orders shall be written, dated, and signed by the person lawfully authorized to give such orders. Prevention of Pressure Ulcer (@ MED-PASS 2001) Purpose documents: The purpose of this procedure is to provide information regarding identification of pressure ulcers risk factors and interventions for specific risk factor. General Guidelines: The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family, and addressed. The care process should include efforts to stabilize, reduce, or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.

Based on interview and record review, the facility failed to follow its fall policy and failed to develop fall prevention interventions to prevent or reduce the risk of falls for 1 of 8 residents reviewed for fall prevention protocols. This failure resulted in R16 having multiple falls and an unwitnessed fall near the bed with blood noted. R16 was sent to the local hospital and assessed with [REDACTED]. Findings include: R16 was admitted on [DATE] with [DIAGNOSES REDACTED]. R16's Minimum Data Set (DS) section G (functional status) dated 10/3/2020 documents: R16 required extensive assistance with one person physical assist with bed mobility and transfers. Walking or turning around did not occur. R16 was not steady without staff assistance moving from seated to standing position or transferring between bed/chair or wheelchair. R16 used a wheelchair for mobility. On 12/24/2020 at 9:50am, V2 (Director of Nursing) said R16 was at high risk for falls based on a history of falls, cognition, difficulty with walking, and thinking he can do things he probably cannot. R16 had an unwitnessed fall on 10/3/2020. R16 was bleeding from the mouth and nose. R16's teeth punctured his lip. R16 had a laceration to the lip and face with swelling to the nose. R16 complained of pain to the right arm. On 12/24/2020 at 11:40am, V8 (Restorative Nurse) said, R16 did not have any interventions in place prior to the fall on 10/3/2020. I put in basic care plan interventions after the fall. R16's fall assessment dated [DATE] documents high risk for falls due to a weak gait and overestimates or forgets limits, and the use of crutches, cane or walker. R16's care plan intervention initiated on 10/02/2020 revised on 10/6/2020 documents: Follow facility fall protocol. Progress note dated 10/3/2020 documents R16 was discharged to the hospital for bleeding on the brain. Incident report dated 10/3/2020 documents R16 had an unwitnessed fall. R16 was noted on the floor near the bed lying on his stomach bleeding from mouth and nose with swelling to the nose. Predisposing factors: R16 was ambulating without assistance. Hospital paper work dated 10/3/2020 documents R16 was diagnosed with [REDACTED].

Based on observation, interview and record review the facility failed to implement the plan of care interventions to include feeding assistance and recommended dietary supplement for 2 of 4 residents (R4, R29) reviewed for nutrition. This failure resulted in R4 having a weight loss of 13.81% in 6 months, and R29 having a weight loss of 14.5% in less than 30 day. Findings include: 1. R4 has [DIAGNOSES REDACTED]. R4's Physician order [REDACTED]. R4's Physician order [REDACTED]. Rec. cont. puree/thin diet texture with 1:1 feeding assistance to utilize aspiration precautions. Refer to speech therapy with any decline in swallowing function. R4's point of care charting for intervention task of ADL (Activities of Daily Living)-eating dated January 2020 shows on the 2nd, 6th, 10th, 12th, 16th, 18th, 19th, 22nd, 25th, 26th there was no documentation showing assistance with feeding was provided by staff. On the 1st, 3rd, 7th, 9th, 14th, 20th, 24th, 27, 28, 29th and 30th there was no documentation showing any feeding support was provided by staff for dinner service. On the 4th, 5th, 11th, 13th, and 17th, there was no documentation showing feeding assistance was provided by staff for breakfast and lunch service. R4's point of care charting for nutrition amount eaten dated January 2020 shows on the 2nd, 6th, 10th, 12th, 16th, 18th, 19th, 22nd, 25th, 26th, there was no documentation showing R4 had eaten breakfast, lunch or dinner. On the 1st, 3rd, 7th, 9th, 14th, 20th, 24th, 27, 28, 29th and 30th there was no documentation showing R4 had eaten dinner. On the 4th, 5th, 11th, 13th, and 17th, there was no documentation showing R4 had eaten breakfast and lunch. R4's point of care charting for intervention task of ADL-eating February 2020 shows on the 3rd, 7th, 8th, 9th, 10th,11th, 14th 15, 16th, 22nd and 23rd there was no documentation showing assistance with feeding was provided by staff. On the 4th, 5th, 12th, and 13th, there was no documentation showing any feeding assistance was provided by staff for dinner service. On the 1st, 6th, 17th, and 18th, there was no documentation showing feeding assistance was provided by staff for breakfast and lunch service. R4's point of care charting for nutrition amount eaten February 2020 shows on the 3rd, 7th, 8th, 9th, 10th,11th, 14th 15, 16th, 22nd and 23rd there is no documentation showing R4 had eaten breakfast, lunch or dinner. On the 4th, 5th, 12th, and 13th, there was no documentation showing R4 had eaten dinner. On the 1st, 6th, 17th, and 18th, there was no documentation showing R4 had eaten breakfast and lunch. R4's point of care charting for intervention task of ADL-eating March 2020 shows on the 1st and 2nd there was no documentation showing any feeding assistance was provided by staff. R4's point of care charting nutrition amount eaten for March 2020 shows on the 1st and 2nd there was no documentation showing R4 had eaten breakfast, lunch or dinner. R4's MDS (Minimum Data Set) dated 2/23/2020 section C shows BIMS (Brief Interview for Mental Status) score of 00 (represents cognitive problems), section G shows R4 needs extensive assist with eating and requires one person physical assist with eating. Section K shows R4's weight was 96 pounds and R4 had a weight loss of 5% or more in 1 month or 10% in 6 months. R4's MDS dated [DATE] section C shows BIMS score of 00 (represents cognitive problems), section G shows R4 needs extensive assist with eating and requires one person physical assist with eating. Section K shows R4 weight was 103 pounds and R4 had a weight loss of 5% or more in 1 month or 10% in 6 months. R4's weight record shows R4 weighed 102.8 pounds on 11/7/2019, 107.2 pounds on 12/5/2019, 104.4 pounds on 12/10/2019, 101.2 pounds on 1/6/2020, 96.4 pounds on 2/4/2020, and 88.6 pounds on 3/3/2020. In one month R4 had a significant weight loss of 6.14%, in 3 months R4 had a significant weight loss of 12.62%, and in 6 months R4 had a significant weight loss of 13.81%. R4's RD (Registered Dietitian) note dated 1/22/2020 shows weight, PMH (past medical history) includes Alzheimer's, DM (Diabetes Mellitus), and Dementia. Ht (height) 60, 1/6 101.2#, 12/5 107.2# (-5.6%), 7/5 112.8# (-10.3%). Weight record indicates significant weight loss x 1, 6 mos (months) possible r/t (related to) variable po (by mouth) intake from 25%-100% of meal. Weight loss unplanned. Needs total assistance with feeding due to cognitive deficit r/t disease process: Alzheimer's, Dementia. Diet: General Pureed with thin liquids, House supplements 240 ml QID (4 times a day) Plan: To prevent further weight loss, will recommend super cereal at breakfast. RD to follow up prn (as needed). R4's RD (Registered Dietitian) note dated 2/10/2020 shows, weight, PMH includes Alzheimer's, DM, Dementia. Diet: General Pureed with thin liquids. House supplements 240 ml QID. Ht 60 BMI=18.8 Lower end of normal range. 2/4 96.4#, 12/5 107.2# (-10.1%), 9/6 109.8# (-12.2%). Weight record indicates significant weight loss x 3, 6 mos possible r/t (related to) variable po intake from 25%-100% of meal. Weight loss unplanned. Staff continues to provide total assistance during meals. Plan: To prevent further weight loss, will recommend super cereal at breakfast, Magic cup at lunch, RD to follow up prn (as needed). Review of R4's physician order [REDACTED]. Review of February 2020 and March 2020 POS there were no orders noted for super cereal at breakfast, there were no orders noted for magic cup at lunch. Review of R4's Medication Administration Record, [REDACTED]. Review of R4's diet slip there are no orders, notes, or alerts for super cereal or magic cup supplements. On 12/24/2020 at 9:33a.m V6 (Dietary Manager) said super cereal and magic cup are nutritional supplements for residents who have concerns with weight loss and R4 did not have any orders for super cereal or magic cup supplements. V6 said it would have been on the diet slip if she (R4) did. On 1/7/21 at 12:35p.m V29 (Unit Manager) said once the information is received from the dietitian, the information is then relayed to the physician for approval or declination. If the physician agrees, the information is sent to the dietary staff and the orders are initiated and also the orders are placed on the physician order [REDACTED]. V29 said R4's dietary recommendations should have been relayed to the physician. On 01/06/21 at 12:17p.m. V20 (Physician) said the resident should receive feeding assist according to the plan of care. V20 said he was not aware of the recommendations from the Registered Dietitian for the super cereal or the magic cup. V20 said he would have agreed to the recommendations and started R4 on the nutritional supplements. V20 said the supplements were recommended to prevent weight loss and R4's weight loss was avoidable. 2. On 12/29/2020 at 9:53 a.m. V26 (Certified Nursing Assistant/CNA) was observed carrying a breakfast tray for R29. V26 said she was discarding the tray. The tray was observed to be undisturbed, the food portion on the plate was not disturbed, the utensils were wrapped in a white napkin, and the clear lid was on the bowl. V26 said R29 did not want to eat. V26 then said, You can ask therapy; they (therapy) tried to feed him (R29). On 12/29/2020 at 9:58 a.m. V27 (Physical Therapist) was observed in the room with R29. V27 said she did not try to feed R29. V27 said she only asked R29 was he hungry. V27 said R29 said he was not hungry. V27 then said she thinks R29 was weak due to him not eating. V27 said R29 was confused. V27 said she was the only therapist in the room with R29; she did not see another therapist trying to feed R29. On 12/29/2020 at 10:02a.m. R29 was observed lying in. R29 was awake, alert to name and birthday. R29 said he was hungry, and no one offered him food. On 12/29/2020 at 10:05a.m V29 (Unit Manager) was made aware that R29 stated that he was hungry, and no one offered him food. On 12/29/2020 at 10:40a.m V26 (CNA) was observed assisting R29 with eating. V26 had to open the beverage for R29. V26 was observed providing total support. R29 drank four ounces of thickened drinks and consumed 98% the food on the plate. Two drinks were noted in R29's room and two drinks were brought in by V26 with the current meal. During the feeding assistance, R29 was observed to say the food was good; when asked did he want more, R29 said no, however R29 was observed to continue to eat and drink the serving as it was being offered to him. R29 was observed swallowing as appropriate and drinking appropriately when assisted. R29 would rest his head on the pillow at times but continue to keep his eyes open and was alert to staff. V26 was observing coaching R29, saying You don't want the food do you, also sayingYou sleepy, huh?., On 12/29/2020 at 3:10p.m V26 said she was assigned to care for R29. V26 said she did not take R29 his breakfast tray that morning. V26 said when the surveyor approached her she was picking up trays after breakfast service. V26 said she had fed all the resident that she was supposed to feed for that breakfast service. When asked who was supposed to feed R29, V26 said everyone is responsible for feeding the residents. V26 said she saw the therapist feeding R29. When asked what feeding assistance did she see the therapist provide, V26 said I just saw the lid off the bowl. V26 said I don't want to lie; I can't speak to what I saw, all I know is she tried to feed R29, then V26 said she saw the therapist bring the plate to R29. V26 said she did not attempt to feed R29 any food; she only asked R29 was he hungry. V26 said whoever brought R29 his tray should have fed him (R29). V26 then said she did not know R29's tray was there. V26 said R29 requires assistance with feeding. On 12/30/2020 at 10:57a.m. V12 (Assistant Director of Nursing) said nurses and CNA are responsible for feeding residents. V12 said staff should not just ask residents if they are hungry, they should make an attempt to feed the resident. V12 said she has to check to see how the feeding assist is assigned. Upon exit from the facility V12 did not give any information on how the feeding assist is assigned. Review of the facility daily assignment sheet for 12/29/2020, there were no assignments made for the residents who needed feeding assistance. On 1/7/21 at 12:35p.m V29 said whoever delivers the food tray to the room should feed the resident. On 1/6/2020 at 10:33a.m V42 (Nurse) said he admitted R29 to the facility and he was notified that R29 requires 1 to1 assist with feeding, and during his initial assessment R29 did need assistance with eating. V42 said he initiated the base line care plan for R29 and documented that R29 requires 1 to 1 assist with feeding. V42 said R29 usually eats 90% of his meal when he is assisted. On 12/30/2020 at 11:06a.m. V14 (Speech Therapist) said R29 requires 1 to 1 assistance with feeding. V14 said this is printed on R29's meal ticket. R29 is at risk for weight loss and is on aspiration precaution. V14 said staff should initiate feeding for 29. V14 said sometimes R29 initiates feeding himself, however he should not be left to eat alone. Due to his cognition R29 puts more food in his mouth and it's not safe so staff should assist. V14 said R29 usually eats at least 75% of meals all the time. R29's Physician order [REDACTED]. R29's point of care charting for intervention task of ADL-eating for December 2020, there is no documentation showing feeding assistance was provided on the 19th, 20th, 25th, 28th, for breakfast and lunch. There was no documentation showing any feeding assistance was provided on the 26th and 27th. R29's point of care charting for intervention task nutrition eaten for December 2020, there was no documentation showing R29 ate breakfast or lunch on the 19th, 20th, 25th, and 28th. There was no documentation showing R29 had eaten breakfast, lunch or dinner on the 26th and 27th. R29's point of care charting for intervention task of ADL-eating for January 2021, there is no documentation showing feeding assistance was provided on 1st and there is no documentation showing feeding assistance was provided on 3rd, 4th and 5th for breakfast and lunch. R29's point of care charting for intervention task nutrition eaten for January 2021, there was no documentation showing R29 ate breakfast or lunch on the 3rd, 4th and 5th. R29's baseline care plan dated 12/18/2020 shows dietary nutrition status, diet order is pureed, thin liquids. Mechanically altered diet: yes. Resident dietary goals; maintain current weight, and prevent weigh loss. Dietary interventions; other; 1:1 feeding. Dietary preference; none. Dietary risk; risk for weight loss, risk for swallowing problems, and risk for chewing problems. R29's comprehensive care plan dated 12/19/2020 shows R29 has nutritional problems or potential nutritional problem r/t pureed, NAS, LCS, low cholesterol diet restrictions. Goal is the resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. R29 will comply with recommended diet daily through review date. R29 will maintain adequate nutritional status as evidenced by maintaining stable weight no s/sx (signs and symptoms) of malnutrition, and consuming food and fluids in adequate amounts to meet maintain optimal health and nutrition through review date. Interventions/tasks are Administer medications as ordered. Monitor/Document for side effects and effectiveness. Assist the resident with developing a support system to aid in wt (weight) loss efforts, including friends, family, other residents, volunteers, etc. Develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food. If unsuccessful at weight loss, or if the resident chooses not to lose weight, refer me to the physician. Assist with obtaining special equipment as needed. Provide and serve diet as ordered. See current Pos. Provide, serve diet as ordered. Monitor intake and record q meal. The resident needs a calm, quiet setting at meal times with adequate eating time. Weigh at same time of day and record per facility protocol. R29's MDS dated [DATE] section G shows R29 requires extensive assist with one person physical assist for eating. R29's hospital records show on 12/14/2020 R29's weight was 171 pounds. During weight observation on 12/29/2020 at 1:27pm with V21 (Restorative Aide), R29 was observed to weigh 144.4 pounds using mechanical lift scale. R29's MDS dated [DATE] (currently in progress) shows R29's admission weight is 168 pounds. R29's face sheet shows admitted [DATE]. R29 had a significant weight loss on 12/29/2020 of 14.5% since admission (11 days). On 1/7/21 at 11:00a.m V12 (ADON) said staff should wake residents up for meals, care planning is based on resident individualized needs, and staff should provide care according to the resident's needs. The feeding assistance is documented in the point of care charting, it should be completed with each meal. If the documentation is not there the task was not completed. If it's not documented that the resident ate a meal, then they didn't eat. The expectation would be for the nurse to relay the information to the provider that day when they receive the information or no later than the next business day. When the dietitian gives recommendations, the recommendation should be relayed to physician by the unit manager, so the provider can decide if they agree or not. On 1/6/21 at 12:01p.m V40 (Physician) said he does not believe R29 had a weight loss of 14.5% in 11 days since admission. V40 said That is a lot of weight in such a short time. V40 said R29 was diagnosed with [REDACTED]. V40 also said it is possible for R29 to lose weight if he's not being fed. V40 said the care plan should be followed. R29's face sheet shows R29 has [DIAGNOSES REDACTED]. Facility policy titled Care Plans - Baseline with revision date 12/2016 shows, policy statement, A baseline care plan to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. Policy interpretations and implementation to assist the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident admission. The Interdisciplinary Team will review the healthcare practitioners orders (dietary needs, medications, routine treatments, etc) and implement a baseline care plan to meet the resident's immediate needs including but not limited to initial goals based on admission orders [REDACTED]. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

Based on observation, interview and record review the facility failed to obtain physician orders [REDACTED]. These failures resulted R342 sustaining pain rated 6 on a 10-point pain scale, R124 sustaining pain rated 15 on a 1-10 scale, and R124 reporting depression related to pain. Findings include: 1. R124's [DIAGNOSES REDACTED]. R124's (1/24/19) POS (physician order [REDACTED]. R124's (6/17/19) care plan states: Administer [MEDICATION NAME] medications as ordered by physician. On 01/06/20 at approximately 9:24 am, R124 appeared uncomfortable, reporting she was in pain and that the nurse was aware. R124 stated she asked for [MEDICATION NAME] last night and was told there were none left and was given Tylenol instead. R124's POS does not include Tylenol. V7 (Registered Nurse) entered the room and stated the facility ran out of R124's [MEDICATION NAME]. R124 responded, What are you doing about it because I'm in a lot of pain. V7 stated she would call the doctor to renew the prescription. R124 reported head and back pain rated 12 on a scale of 1-10, which was causing depression. R124's (January 2020) Controlled Drug Record affirms [MEDICATION NAME] was administered twice daily from 1/1/20-1/4/20. On 1/5/20 (6am) there were zero amount left. On 01/07/20 at 1:51 pm, V29 (Licensed Practical Nurse) stated R124 asked her for [MEDICATION NAME] during the 8:00am medication pass however the medication had not arrived yet from the pharmacy. The night nurse gave Tylenol for pain because they were still out of the [MEDICATION NAME]. On 1/07/20 at 1:53 pm, R124 was restless, appeared uncomfortable, and stated, I'm in pain. Surveyor inquired what her pain was rated on a scale of 1 to 10. R124 responded 15. R124 stated she cannot eat because of pain. R124's lunch was untouched. On 01/07/20 3:56 pm, V31 (Medical Director) stated physician orders [REDACTED]. The expectation is for the nurse to assess the patient, document pain level and administer medication as warranted. The facility's Emergency Use Medication List affirms [MEDICATION NAME] 10/325 mg was available. On 1/08/20 at 10:24 am, V2 (Director of Nursing) reviewed R124's (January 2020) POS and affirmed Tylenol was not prescribed. 2. R342's [DIAGNOSES REDACTED]. R342's POS (Physician order [REDACTED]. On 1/6/20 at 9:46am, R342 was lying in bed and appeared uncomfortable. R342 stated, I'm in a lot of pain in my neck and my tailbone. I've got two bulging discs and have arthritis in my neck where most of the pain is. Surveyor inquired what R342's pain was currently rated on a 1-10 scale; R342 responded, About a six. On 1/6/20 at approximately 9:49am, surveyor inquired when R342 last received pain medication. V4 (Licensed Practical Nurse) reviewed the EMR (Electronic Medical Record) and stated, He hasn't had anything for pain. He has [MEDICATION NAME] every eight hours scheduled for 6am, 2pm, and 10pm. V4 reviewed R342's controlled substance ([MEDICATION NAME]) sign out sheet and stated, Last night at 10pm was the last dose he received. On 1/6/20 at 9:51am, surveyor inquired about R342's positioning. V4 stated, It looks uncomfortable; he needs to be repositioned. R342'S (January 2020) MAR (Medication Administration Record) and controlled substance log affirm [MEDICATION NAME] was not administered on 1/6/20 (at 6:00am) as prescribed. The Administering Pain Medications policy (revised 4/2007) states: Follow the medication administration guidelines in the policy entitled Administering Medications. The resident's experience of pain is highly individual and subjective. Pain is whatever the resident says it is. Identify individuals who have pain or who are at risk for having pain. This includes a review of known [DIAGNOSES REDACTED]. Identify the nature and severity of pain including characteristics. Use a standardized pain assessment instrument appropriate to the resident's cognitive level. 3. On 01/07/20 at 10:00 AM R74 complained of severe pain on Friday 1/3/2020. R7 stated that he went without a pain patch for a whole day. R74 stated the pain was so severe that he was crying. R74 stated the nurses did not re-order his pain medication on time. R74 stated, The nurses are not doing their job in getting the medication re-ordered by the doctor on time. R74's Electronic Medical Record showed that on 1/3/2020, R74's [MEDICATION NAME] was not administered to R74 and was documented as refused. R74's controlled drug receipt record/disposition record showed that the last [MEDICATION NAME] was administered on 12/31/19 at 6:00am and the next dose was administered on 1/4/2020. R74 has an order for [REDACTED]. V2 (Director of Nurses) stated the [MEDICATION NAME] was not available because it was not reordered until 1/4/2020. V2 presented the copy of the order dated 1/4/2020. On 1/7/2020 at approximately 1:00pm, V35 (Pharmacist Customer Service) stated that two (2) of ten [MEDICATION NAME] medications ordered were delivered to the facility on [DATE] at 6:35pm. V35 stated the remaining will be delivered on 1/8/2020. R74's plan of care initiated 8/30/2018 focus on R74 being on pain medication therapy related to chronic pain and the goal includes but is not limited for him to be free of any discomfort. The facility policy titled Receiving Controlled Substances with no revised date, documented that controlled substances are re-ordered when a four (4) day supply remains to allow for transmittal of the required written prescription of the pharmacist.

Based on interview and record review the facility failed to implement interventions to address a resident's refusal to eat for several days for 1 of 3 residents (R1) reviewed for hydration in a total sample of 8. This failure resulted in R1 being transferred to the local hospital with dehydration, pancreatitis and acute kidney injury. Findings Include: The Nurse's Notes dated 9/25/19 document that R1 was not eating and refusing all medication. R1 was educated on medications and continued to refuse. The MD and family were notified and there were no new orders received. The Nurse's Notes dated 9/27/19 documents that R1 was noted with a poor appetite. R1 refused to eat breakfast and lunch. Resident stated, I just want to lay down. I don't want no food. The Nurse's Notes dated 10/2/19 document that R1 was noted very lethargic and refused meals for 4 days. The MD and family aware. Resident transferred to the local hospital for evaluation and treatment. The hospital records dated 10/2/19 document that R1was admitted with a pressure ulcer to the coccyx and a deep tissue injury to the heels. R1 was given IV fluids for acute kidney injury, pancreatitis, and dehydration. R1's Blood Urea Nitrogen (BUN) levels were 182mg/dl (normal range 7 to 20mg/dl), Creatinine levels were 6.9mg/dl (normal range 0.5 to 1.1mg/dl), increased BUN and Creatinine indicates kidney injury and dehydration. The resident's acute kidney injury and acute pancreatitis were resolved after IV fluids were administered. R1 was readmitted to the facility on [DATE]. Facility has no documentation to indicate that a Physician was notified of the resident's change in condition with R1 not eating from 9/26/19 through 10/1/19. On 11/5/19 at 11:35pm V11 (Restorative Nurse) stated, I was feeding R1 on 9/27/19 and the resident was refusing to eat. I notified the family about the change. I never notified the Physician. The primary nurses usually call the Physician. On 11/6/19 at 11:00am V12 (Nurse) stated, I saw the resident prior to R1 being transferred out of the facility. R1 was lethargic and had not been eating for a few days. I never notified the Physician about any changes. The nurses caring for the resident should call to report changes.

Based on interview and record review the facility failed to develop a plan of care with intervention to ensure safety during transfers for 1 of 3 residents (R1) reviewed for safe transfers. This failure resulted in R1 having 2 falls during staff assisted transfers on 07/08/19, and the second fall R1 sustained a laceration to the left lower leg requiring sutures at the local hospital. Findings include: R1's clinical records shows R1 has [DIAGNOSES REDACTED]. R1's progress note dated 7/2/19 at 12:17a.m documents admission summary, resident (R1) 72 y/o (year old) female who went to local hospital ER (emergency room ) on 27th post fall, admitted for left leg pain and [MEDICAL CONDITION]. On 8/27/19 at 2:24p.m V10 (Physical Therapist) stated R1 was admitted to the facility post fall at home. R1 had an injury to the left lateral knee (hematoma). V10 said R1 presented with gross weakness and left lower extremity pain reducing functional mobility compared to independent prior level of functioning. V10 said R1 required moderate assist when transferring from sitting to standing position, meaning staff is providing 50% of weight bearing support. V10 said R1's standing balance is fair minus meaning R1 needed to hold on to a four leg walker so that she does not lose her balance when standing during a transfer. V10 said R1 required a four leg walker during all transfers from sitting to standing. R1's physical therapy evaluation and treatment dated 7/2/19 shows reason for referral as patient referred to PT (physical therapy) due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, decrease in range of motion, reduced ability to safely ambulate, reduced functional activity tolerance, increased need for assistance from others and pain indicating the need for PT to evaluate for assistive devices, increased independence with gait, facilitate with all functional mobility, promote safety awareness, improve dynamic balance, increase functional activity tolerance, increase LE ROM (lower extremity range of motion) and strength, decrease complaints of pain and facilitate discharge planning. RLE (right lower extremity) WFL (within functional limits), LLE ROM impaired (limited range of motion of left knee and ankle secondary to pain). Static standing fair (-) (minimum Assist or UE support to stand w/o LOB to reach ipsilateral; unable to weight shift) dynamic standing is Fair (-) (minimum Assist or UE (upper extremity) support to stand w/o LOB to reach ipsilateral; unable to weight shift. R1's fall scale dated 7/2/19 documents fall scale is 50, category is high risk for falls. R1 has history of falls; R1 has more than one diagnosis; ambulatory aid used number 1 is checked for none/wheel chair/bedrest/nurse assist; gait is checked for weak; and mental status shows R1 knows the limits of her ability to ambulate safely. R1's baseline care plan dated 7/1/2019 documents Section B - Functional abilities and goals - mobility - bed mobility support provided one person physical assist, transfer support provided two plus person physical assist, walk in the room support provided two plus person physical assist, walk in corridor support provided two plus person assist and locomotion on unit support provided two person plus physical assist. Section H - safety risk, does resident have a history of falls? Yes is documented. Did resident have a fall any time in the last month prior to admission/entry or reentry? Yes is documented. Specify fall during the last month prior to admission? Post fall is documented. Did resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? Yes is documented. Specify fall during 2-6 months prior to admission, post fall is documented. On 8/30/19 11:30a.m.V2 said the facility develop care plans within 5 days of admission and R1's plan of care was individualized. R1's care plan dated 7/8/19 documents the resident (R1) is high risk for falls related to gait/balance problems. The goal will be free of falls through the next review date. Interventions are to anticipate and meet the resident's needs, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and review information on past falls and attempt to determine cause of falls. Record possible root cause, alter/remove any potential causes if possible. Educate resident/family/care givers/IDT as to cause. R1's individualized plan of care were without documentation showing how much physical assistance/weight bearing R1 required during a transfer and there were no documentation noted for the use of four leg walker during transfer to assist with standing balance Facility incident report titled other injury dated 7/8/19 at 10:57a.m completed by V5 (Nurse) shows Resident (R1), incident location - resident room, revision date 7/8/19at 3:15pm, resident complained of pain to the left knee upon assessment resident had a purple bruising on the knee. Painful to touch. Assess resident left leg, swelling noted, called MD, order received to x-ray left leg, gave resident pain pill as ordered, notified resident family. No injuries observed at the time of the incident. Pain level 8, alert, ambulatory with assistance. Mental status orientated to person, place, situation and time. Injury type - bruise left knee front. Predisposing physiological factors - others is checked. Predisposing situation factors - ambulating with assist is checked. Witnesses' shows other dated 7/8/19. People notified shows physician and family. On 8/27/19 at 1:45p.m. V6 (Certified Nursing Assistant/CNA) said on 7/8/19 during the morning, she was assisting V9 (CNA) with transferring R1 from bed to wheelchair. V6 said R1 was rocking herself forward in an attempt to stand. Once R1 stood up (independently), R1's bed moved. R1 lost her balance and R1 plopped back down on the bed. V6 said R1 was using the bed rail (on the right hand side) for support in the attempt to stand. V6 said after that she (V6) told (V9) to lock the wheels on the left side of R1's bed. V6 and V9 then assisted R1 to the wheel chair with the wheelchair. V6 (CNA) said the bed should be checked to ensure that it is locked prior to transferring a resident from bed to wheelchair. V6 said the bed should be locked for safety reasons. V6 said they did not use a four leg walker to assist R1 with her standing balance during the transfer. V6 said she reviewed R1's care card to determine that R1 required two person assist with transferring. Review of R1's care card dated 7/2/19 shows transfer 2 assist box is checked; there was no documentation noted to use a four leg walker to assist with standing balance. On 8/29/19 at 2:01p.m. V11 (Restorative Nurse) said R1 required 2 person assist with transfers. V11 said all the aides know to check the care card prior to assisting any residents with a surface to surface transfer. V11 said the card care is completed by her after the physical therapist does the evaluation of the resident. V11 said the care card shows how many assist is needed during bed mobility and transfers, if resident requires a mechanical lift, and devices needed during transferring. V11 said there is not a box to check on the form if the resident used a four leg walker for standing balance during a transfer. V11 said she did not write the information in on the form because she did not think she saw it on the Physical Therapy evaluation. Several calls made to V9, no answer, message left. A review of V9's written statement dated 7/8/19 documents M.O assisting resident from bed to wheelchair. Aide (V9) went to get help with transfer after getting resident ready for the day, lead (V6) attempted to sit resident on the side of the bed, while doing so the resident expressed her leg was hurting and had been hurting for a while. After sitting on the bedside the resident tried to stand but could not. After the second try she was able to stand but the bed moved back and the resident slid back onto the bed. The aide (V9) then immediately locked the bed. The resident (R1) attempt to get in the chair once more and the mission was accomplished. Aide is (V9), Lead is (V6), resident (room number) - (R1). On 8/29/19 at 10:40a.m V5 (Nurse) said it was reported to her on 7/8/19 by V6 and V9 that during transfer of R1 from bed to wheelchair R1 stood up and R1 fall back on to the bed because the bed was not locked. V5 said she notified the physician and an X-ray was ordered of the left knee. V5 said the bed should be locked during all transfers and the bed should be checked prior to transferring any resident. A review of R1's physical therapy treatment encounter notes dated 7/8/19 at 1:37pm shows resident (R1) entered session stating she twisted her knee this AM. Observed LLE (left lower extremity) swelling. Ice applied at the end of session for pain relief. Gait: instructed resident on gait training emphasis on with bariatric RW (roller walker), w/c (wheel chair) follow, 3L oxygen, 2x 30 feet. No knee buckling observed during mobility. Resident (R1) declined stair climbing today secondary to LLE discomfort. Facility incident report titled fall during staff dated 7/8/19 at 6:50p.m completed by V8 (LPN) shows resident (R1), incident location - resident room, revision date 7/15/19 at 11:03pm, writer alerted to resident room by family. Resident (R1) observed lying supine on the floor next to the bed. Blood noted to (L) leg. Assessment completed by nurse (V13). Resident remains alert and orientated x3 during assessment. Writer called 911 for ambulance to be dispatched to facility. Upon return to resident's room, writer noted tourniquet and dressing to lower left extremity. Taken to hospital - Y. Injury type - laceration left lower leg (front). Level of conscious - alert. Predisposing environmental factors none is checked, Predisposing physiological factors - weakness/fainted is checked. Predisposing situation factors - during transfer is checked. No witnesses found. Family member notified on 7/8/19 at 6:50p.m. On 8/27/19 at 12:19p.m V7 (CNA) said she was transferring R1 on 7/8/19 around 6:30 p.m. from bed to the wheelchair with the assistant from R1's family. V7 said she assisted R1 to a standing position. R1 was moving slowly. One step of trying to pivot, R1 complained about her leg giving out and R1's leg start buckling and R1 was eased to the floor. V7 said once R1 was on the floor, she (V7) noticed blood coming from R1's leg and upon lifting R1's pant leg she (V7) noticed R1's leg was cut open. V7 said she did not check the point care click system to determine what type of physical assist R1 required prior to assisting R1 with the transfer. V7 said she was the only facility staff assisting with R1's transfer. V7 said she did not use a four leg walker to assist with R1 standing balance. On 8/27/19 at 4:58p.m V8 (Nurse) said it was reported to her on 7/8/19 that during transfer of R1 by V7 and a family member, R1 stood up, R1 complained that her knee was giving out and R1 was lowered to the floor. V8 said she does not have more details because she was not in the room when the incident occurred. R1's progress notes dated 7/8/19 at 6:50p.m show writer (V8) alerted to resident's room by family. Resident observed lying supine on the floor next to the bed. Blood noted to (L) leg. Assessment completed by nurse. Resident remains alert and oriented times 3 during assessment. Writer called 9-1-1 for ambulance to be dispatched to facility. Upon return to resident's room, writer noted a tourniquet and dressing to lower left extremity. A review of R1's progress notes dated 7/8/19 at 10:39p.m document 72 y/o (year old) female A/OX3 (alert and oriented time 3) with no signs of any distress alerted by family member that her mother is bleeding everywhere. Patient observed lying on floor with left leg soaked in blood. Assessment performed and left leg noted with large deep wound laceration to left leg with bleeding noted still. Tourniquet applied above the left leg wound laceration and bleeding stopped. Left leg wound packed with wet saline and covered with (namebrand) pads and dressing. Daughter stated she and the CNA were transferring her mother to bed and when she stood up, her leg gave out and collapsed. Patient denies any pain, L[NAME] (loss of consciousness), dizziness, or blurred vision. 911 initiated and arrived on scene. Crew arrived on scene, patient care transferred to medics with paperwork. Patient left on stretcher to ER (emergency room ). R1's hospital records dated 7/8/19 at 8:10pm document trauma history and physical, patient seen immediately upon admission, [AGE] year old female with history of [MEDICAL CONDITION] (Chronic Obstructed [MEDICAL CONDITION] Disease),[MEDICAL CONDITION](Hypertension), [MEDICAL CONDITIONS] presenting after fall with leg laceration. Patient resides in a nursing home and reports having a fall, and then had a laceration of her leg. Physical exam, skin 20x 7 centimeters laceration to left medial lower leg without active bleeding, 10 cm bruising to left inner thigh. Diagnosis, left leg laceration. Facility policy titled Transfer activities dated 2006, basic responsibility licensed nurse and nursing aide, restorative nursing assistant, other. Purpose, to transfer the resident from bed to chair, toilet or tube safely. Equipment positioning devices as necessary, transfer belt. Facility policy titled Safe lifting movement of residents dated 2001 with revised date 2008 documents in order to protect the safety and well-being of staff and residents and to promote quality care this facility uses mechanical lifting devices for the lifting and moving of residents. The transferring needs of residents shall be assessed on an ongoing bases. Residents transferring and lifting needs shall be documented in the care plan. Assessment of the resident transferring needs shall include, mobility of the resident (degree of dependency), size of the resident, weight bearing ability, and cognitive status. Facility policy titled transfers and lifts with no facility name, no effective date, no approved by name, no date, no revision date, documents the resident care plan should be explicit on exactly how to be transferred or lifted. Know the resident's weight bearing status and balance problems. Make sure all equipment or assistance is available.

Based on interview and record review, the facility failed to implement interventions for behaviors resulting in falls, provide supervision to a resident with a history of falls, and initiate an investigation for two falls for one (R3) of 3 residents reviewed for falls in the sample of 3. These failures resulted in R3 sustaining a [MEDICAL CONDITION] requiring surgical intervention. Findings include: R3 is an [AGE] year old, non-ambulatory female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 is cognitively impaired per the Brief Interview for Mental Status (BIMS) of 8 indicating impairment per the significant Minimum Data Set ((MDS) dated [DATE]. R3's fall assessments dated 5/20/19, 6/21/19, 6/25/19 and 7/1/19 document R3 to be high risk for falls due to unsteady gait, decreased safety awareness due to impaired cognition and history of falls. On 7/12/19 at 3 PM, V2 (Vice President of Operations) stated R3 was known to have frequent falls and presented R3's clinical chart from R3's previous facility. The previous facility nurses' notes and social service notes (5/8/19, 5/7/19, 4/5/19, 4/30/19, 4/13/19, 4/10/19, 4/2/19, 4/1/19) document the repetitive standing from wheelchair, wandering/propelling around the nursing unit, falling and sustaining lacerations, being very confused and refusing medication. Care Conference note 4/4/19 documents multiple daughters, POA and son were present and the discussion was related to R3's multiple falls. Family stated She is constantly falling at home and multiple prior facilities. We know she continues to strive to be independent but is not safe. We try to redirect her but she continues to act up. R3 sustained 2 falls in this facility, one on 6/21/19 and the other on 7/1/19. There was no investigation into each fall. The 6/21/19 nurses' incident note documents R3 fell in the television lounge. The documentation also includes assessment was done, no obvious injuries and resident refused her vitals being taken. R3 denies pain. Attempts to contact family and physician. Later, an x-ray order obtained. This nurses' note was entered into the computer system on 6/25/19 by V6 (Licensed Practical Nurse/LPN) 4 days after the incident. On 7/12/19 at 3 PM, V3 (Director of Nursing/DON) stated that V6 failed to document the fall. V3 stated that V4 (Assistant Director of Nursing/ADON) had V6 write a statement on 6/25/19 for R3's fall. V6 has since resigned. The nurses note 6/21/19 at 11:30 PM documents R3 refusing medications, kicking, screaming, biting and nurse holding her intravenous medication for safety reasons. Nurses' note dated 6/22/19 at 11:30 PM by V6 documents R3 being sent to hospital related to the x-ray results which showed [MEDICAL CONDITION]. R3 returned to the facility on [DATE] with 16 staples to the left hip per restorative note. R3 was in the hospital from 6/23/19 to 6/26/19. Nurse Practitioner progress note 7/2/19 documents R3 having surgery to the right hip with nailing and staples for closure. On 7/15/19 at 12:41 PM, V5 (Certified Nurse Aide/CNA) stated she was assigned to R3 on the evening shift of 6/21/19. V5 stated R3 was propelling herself around the unit in her wheelchair. V5 stated that R3 was continuously trying to stand up from her wheelchair. R3 would use the hall grab bars to stand up from her wheelchair. V5 stated R3 was very agitated and a little combative. V5 stated that V6 and V10 (LPN) were passing medications. V5 stated that R3 stood up from her wheelchair, her knees buckled and she fell to her side. This all happened by the 3rd floor television lounge. V5 stated that she and another CNA (V5 does not recall who the other CNA was) picked R3 off the floor and placed her back in her wheelchair. V5 stated she could not recall if she and the other CNA had their hands on R3 to break R3's fall but added that R3 did not hit her head on the floor. V5 stated she was not questioned about this fall or asked to write a statement. The facility's incident report dated 6/21/19 documents the fall was witnessed and R3 was agitated and slipped off the edge of the wheelchair landing on her left side. There were no staff statements as to what had occurred or what was witnessed. Attempts to contact V6 were unsuccessful. On 7/15/19 at 2:53 PM, V11 (CNA) stated R3 continuously stands from her wheelchair using the hall grab bars and does a side step along the hall railings/grab bars. V11 stated that R3 is feisty, hard to redirect and tries to hit the staff. V11 stated that R3 used her wheelchair's foot rest and tried to hit a CNA with it. V11 stated R3 is not understood due to gibberish speech. V1 stated when R3 is agitated and not re-directable, nothing is done. R3 is left alone. On 7/15/19 at V10 (LPN) stated that R3 is a sundowner and is non-compliant with staying in her wheelchair. V10 stated that R3 will continuously stand from wheelchair and take a few shuffled steps and nurses will assist R3 back to sitting. V10 stated that the footrests on the wheelchair blocks her from going any distance and nurses are able to redirect her. Nurses' incident note dated 7/1/19 documents at 7:45 AM, R3 is found on the floor wrapped in covers on the right side of the bed. R3's head was resting on a slipper. It was an unwitnessed fall. The facility's incident report documents the same. There was no investigation into the fall. On 7/15/19 at 12:45 PM, V12 (LPN) stated she recalls finding R3 on the bare floor and asking for a floor mat to put down for R3. V12 stated the bed was in the lowest position about 17 inches from the floor. On 7/15/19 at 9:10 AM, V3 stated there was no investigation into the 7/1/19 fall for R3. Review of R3's fall risk care plan 5/30/19 documents the following fall interventions: anticipate and meet resident's needs, ensure call light is within reach, educate resident and family about safety, Physical Therapy to evaluate and treat and review information on past falls and attempt to determine cause of fall. Record possible root causes. The fall care plan was updated on 6/23/19 to continue the at-risk plan, monitor, document and report any signs or symptoms for 72 hours following the fall to the physician, provide activities that promote exercise and strength building where possible and consult physical therapy for strength and mobility. The facility's policy Accidents/Incidents/Events - Investigating and Reporting documents should you witness an accident, render immediate assistance. Do not move the victim until she has been examined for possible injuries. The nurse supervisor or Charge nurse shall examine the victim and must conduct an immediate investigation of the incident. The following data must be included in the report, such as, the time and date of the incident, the circumstance surrounding the incident, the names of witnesses and their accounts of the incident, the injured person's account, the time the injured person's attending physician was notified as well as the the time the attending physician responded with his instructions, the time and date the injured person's family was notified and by whom, the condition of the injured person including vitals and the disposition of the injured and any corrective action taken, follow-up information and the signature and title of the person completing the report. This report must be submitted to the Director of Nursing no later than 12 hours after the occurrence and to the administrator no later than 24 hours after the incident. This policy was not followed. The facility's policy Evaluating Falls and Their Causes documents the purpose of this policy is to provide guidelines for evaluating a resident after the fall and to assist staff in identifying causes of the fall. After a fall, a resident is observed on the floor, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities. When a fall results in significant injury or condition change, nursing staff will notify the practitioner immediately by phone. Nursing staff will observe for delayed complications of a fall for approximately 72 hours after an observed or suspected fall and will document findings in medical record. The documentation will include at least statements about observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility. All incident reports must be completed for resident falls. The incident report form will be completed by the nursing supervisor on duty at the time and submit the report to the Director of Nursing no later than 12 hours after the fall occurs. Identifying the cause of the fall, nursing will begin to identify possible or likely cause of the incident. The Unit Manager or the Director of Nursing should consult with the attending physician or Medical Director to confirm specific causes from among multiple possibilities and document the basis for identifying specific factors as the cause. This policy was not followed.

Based on interview and record review the facility failed to use proper dressing techniques while rendering activity of daily living (ADL) care for a cognitively impaired resident with limited mobility and range of motion for 1 of 3 residents (R1) reviewed for accommodation of needs in a total sample of 6. This failure resulted in R1 being observed with swelling to the right arm after ADL care and being hospitalized with a [DIAGNOSES REDACTED]. Findings Include: The Face Sheet documents that R1was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R1 has functional limitation in range of motion (ROM) related to an impairment to the upper extremity and requires total care for ADLs. The care plan dated 8/23/18 documents that R1 has activity intolerance and staff should assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self with 1-2 staff assistance as needed. The Incident Report dated 3/8/19 documents that on 3/7/19 R1 was observed with the right arm swollen and warm. The Nurse Practitioner (NP) Note dated 3/7/19 at 4:04pm documents that R1 was assessed and noted with swelling to the right arm that was tender to touch and orders were given for an x-ray to be done. The x-ray report documents that the scan was done on 3/8/19 at 5:04am and showed a spiral fracture to the right lower arm. The Physician was notified and R1 was transferred to the local hospital for evaluation and treatment. The Hospital Records dated 3/8/19 at 10:44am documents that R1 has a confirmed spiral fracture to the right forearm. R1 observed hugging arms close to the body and will not follow commands. R1 appears to be afraid but is quiet at this time. R1 withdraws to pain and says ouch when palpating bilateral upper extremities. Right distal forearm was slightly more swollen compared to the left. R1 unable to tolerate placing arm on the board for x-rays. R1's arm was splinted and the resident was sent back to Nursing Home with a [DIAGNOSES REDACTED]. On 4/18/19 at 3:33pm V4 (CNA) stated, I was the CNA for this resident. When I started my shift I didn't notice any swelling. I came in the room between 4 and 5am to get the resident dressed. I put one arm in the shirt first. I grabbed the resident by the right wrist and was trying to guide the right arm through the shirt. The resident pulls away from you and was twisting the arm while I was holding it. The resident can be a little resistive to care. Another CNA came in to help transfer the resident to the chair. I noticed some swelling to the right arm prior to the transfer. I notified the CNA and the Nurse so they could monitor the resident because it was the end of my shift. R1 is resistive at times but only requires 1 person assist with dressing and 2 person assist with transfers and ambulation. The resident makes noises and grunts a lot. There was some facial expressions at the time but the resident never yelled out. On 4/23/19 at 1:01pm V8 (CNA) stated, If a resident is being combative during care, then you stop and wait for them to calm down before you start again. If they still are trying to fight me, then I go and get the nurse. I might try to help guide their arms or legs through clothing, but I would never grab them. If they are swinging at me, I just back away. On 4/23/19 at 1:40pm V2 (DON) stated, The resident has very rigid arms and leans more to the right side. The resident does not work with you and it can be difficult to provide care. The way it was explained to me was that the CNA was getting the resident dressed and trying to put R1 in a long sleeved shirt. The resident was unable to push the arm through so the CNA pulled the right arm to guide it through the shirt. Being that the resident leans to the right side, I can see how pulling the arm could have caused the fracture. I would have expected staff to notify me or the CNA supervisors to let me know that using one person to dress the resident was not working so we could've made some changes. I did educate all of the staff on reporting things they may see when providing care and we're now using 2 people for this resident and other residents that are similar. On 4/24/19 at 11:40am V11 (Physician) stated, A spiral fracture is caused by a force that is rotating or twisting the bone. If the resident's arm was being held or the resident got the arm stuck in a side rail and began twisting the arm you would likely see a spiral fracture because the resident is elderly and very frail.

Based on interview and record review the facility failed to follow their policy on management of low blood sugar for one (R1) resident out of three residents reviewed for blood sugar monitoring and treatment resulting in altered mental status related to prolonged [DIAGNOSES REDACTED] (Toxic metabolic [MEDICAL CONDITION]). Findings Include: R1 is an [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. R1 was transferred to local community hospital via local emergency medical services at 4:33am on [DATE] with admitting [DIAGNOSES REDACTED]. Record review of facility's documents: R1's nurse's progress notes reads that on [DATE] at 3:15am, R1 was noticed laying in bed, breathing, skin cold to touch and clammy, verbally unresponsive, drooling on the right side of the mouth, spasms noted on fingers. Head of the bed elevated, unable to obtain temperature reading, Blood sugar monitored with a result of 55mg/dl (milligrams/deciliter). At 3:32 am, Physician was called and physician ordered to send the resident to emergency room (ER). At 3:35am, local private ambulance was called and was given estimated arrival time of ,[DATE] minutes. Blood glucose rechecked and obtained a result of 52mg/dl. At 3:40am, 911 was called and ambulance arrived and assessed, transferred resident to local community hospital. Local private ambulance was cancelled. At 4:00am, ER (emergency room ) and family member were notified of R1's transfer. At 7:45am, local community hospital updated that R1 was admitted for [DIAGNOSES REDACTED] and Altered Mental Status. Family was notified of the update. R1's initial nurse screening at the time of admission on [DATE] at 7:17pm documents for mental status - alert, oriented to person, place and situation. R1's MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview of Mental status) score of 12 out of 15. R1's POS (Physician order [REDACTED]. Chart and rotate sites, do not mix with any other Insulin, High alert drug; [MEDICATION NAME] R-100 units/ml (Mililiter) Inject 5(five) units subcutaneous three times daily with breakfast (8:00am), lunch (12:00pm) and dinner (5:00pm), high alert drug. R1's POS on the right side of the sheet (Standing Orders) also documents: Monitoring orders - (MONTH) give [MEDICATION NAME] 1 MG (Milligram) intramuscularly as needed for diabetic residents with blood sugar level below 70 and if unresponsive. Certification: physician's orders [REDACTED]. R1 was started on antibiotic [MEDICATION NAME] 250 mg by mouth two times a day for 7 (seven) days started on [DATE] for Urinary Tract Infection [MEDICAL CONDITION]. R1's nursing care plan dated [DATE] documents: The resident (R1) has a [DIAGNOSES REDACTED]. Approach: Nurses observe and document signs and symptoms of [DIAGNOSES REDACTED] (Heart palpitations, fatigue, pale skin, shakiness, anxiety, sweating, hunger, irritability, confusion, impaired vision). Notify physician as appropriate. Provide diet as ordered. Administer meds as ordered. See POS/MAR. Blood glucose monitoring as ordered. Implement and maintain safety precautions. Goals: The resident (R1) will not exhibit signs and symptoms of hypo/[MEDICAL CONDITION] through next review. Resident's blood glucose will be maintained within reasonable limits with diet and medication through next review. Record review of EMS (Emergency Medical Services) documents: 1. R1's EMS (Emergency Medical Services) Notes dated [DATE] reads Chief complaint: Diabetic symptoms - low blood sugar. At 04:01 am, Blood Glucose 40mg/dl and 04:11 [MEDICATION NAME] 1mg (1 unit) Intramuscular injection was given by paramedics. Comments: Patient (R1) found laying in bed, alert only to painful stimuli. Staff stated that patient (R1's) blood sugar was low. At the time of the service, the patient was physically unable to follow commands and sign. Record review of ER (emergency room ) and hospital documents: ER (emergency room ) History and Physical documents that R1 arrived at 4:33 with blood glucose of 18mg/dl and with admitting [DIAGNOSES REDACTED]. Local community hospital History and Physical (H&P) documents: R1 was brought in for change in mental status and severe [DIAGNOSES REDACTED]. She (R1) recorded at 18 in our ER. Details around what time medications she (R1) was given Insulin and what corrective measures were provided are not reliable at this time but concern is apparent for an extended period of [DIAGNOSES REDACTED]. This is because, after she arrived in ER with a low blood sugar, she was very quickly treated and blood sugar corrected to levels above 200mg/dl. She has however, not regained her baseline neurologic state but remains non-verbal, we are concerned as well that a prolonged course of [DIAGNOSES REDACTED] may be a precipitating factor. Impression and plan: [MEDICAL CONDITION] possible secondary to prolonged hypoglycemic episode. CT Scan and MRI (Special X-ray's) head - No acute intracranial abnormality and no bleed. Discharge summary dated [DATE] by the ER physician documents: R1's blood sugar at ER upon recorded as 18mg/dl but was noted to below the night before. Details around what medications R1 was given (Insulin) and what corrective measures were provided are not reliable at this time but concern is apparent for an extended period of [DIAGNOSES REDACTED]. This is because after R1 arrived with a low blood sugar, she (R1) was very quickly treated and blood sugar corrected to levels above 200. R1 has, however not regained her baseline neurologic state but remains non-verbal. Her Urinalysis was suspicious for UTI and she has had previous admissions for Urinary Tract Infection [MEDICAL CONDITION] with [MEDICAL CONDITION]. Resident's white cell count is 7.8 cells/micro liter - does not indicate any infection. ER physician has spoken to the family and told them that the physician is concerned as well that a prolonged course of [DIAGNOSES REDACTED] may be a precipitating factor. Special X-ray (CT scan) of the head was without bleed. Electro Encephalo Graphy (EEG) on [DATE] and [DATE] indicated that the EEG was abnormal due to moderate generalized slowing, which indicates diffuse cerebral dysfunction as seen in toxic metabolic [MEDICAL CONDITION]. No electrographic [MEDICAL CONDITION]. Hospital Course: R1 presented with altered mental status and severe [DIAGNOSES REDACTED]. R1's mentation did not improve despite normalization of blood sugar. Neurology consult indicated that prolonged [DIAGNOSES REDACTED] is the reason for [MEDICAL CONDITION]. Given prolonged altered mental status, R1 was started on nasogastric tube feeds. However, given overall minimal improvement in mentation goals were discussed with family. Family decided to keep R1 in hospice care and eventually R1 died on [DATE]. On [DATE] at 3:00pm, V2 (DON) stated Our nurse checked blood sugar and it was 55mg/dl, resident was unresponsive, and nurse called the physician and physician ordered to transfer the resident to ER. Nurse rechecked blood sugar - 52mg/dl. No medications were given to the resident at this time. Local ambulance was called and they gave her wait time of 25 minutes, then 911 was called and resident was transferred to local community hospital ER. Our nurse documented everything as she did. On [DATE] at 3:25pm, V14 (Pharmacist) stated The orders on the right side of the POS are called standing orders and the order for [MEDICATION NAME] is a standing order for this resident (R1). The POS is a typed/computer generated document which is produced by the pharmacy after the transcription of the orders from the physician. If a resident has a standing order for [MEDICATION NAME], the nurse can obtain the medication from emergency medication kit of that unit. On [DATE] at 11:16am, V10 (Medical Director) stated As per the ADA (American Diabetic Association) when a nurse calls the physician for treatment of [REDACTED]. He (V13 - Physician on call) is supposed to make decisions for his residents. I don't know, why he didn't order that. On [DATE] at 11:45am, V11 (Licensed Practical Nurse-LPN) stated I took care of this resident only for two days. As much as I know, this resident is alert, oriented to name and place, when I take medications to her, she was able to follow the commands to sit up, open eyes, take meds and water, say thank you and goes back to sleep. I was aware that she was diabetic; I never offered her any bedtime snack. On [DATE] when I received this resident at the beginning of my shift, at 11:00pm, she was sleeping, I didn't see her in distress, didn't wake her up. Generally I don't take vital signs at 11:00pm; I take at 3:00am. On [DATE] at 3:00am, when I was trying to check vital signs, I found her sweating, cold and clammy, checked her blood sugar, it was 55mg/dl. I checked the emergency kit for [MEDICATION NAME] injection and I couldn't find any. I called V13 (Physician on call) and he ordered to transfer the resident to ER; no orders for [MEDICATION NAME] were given at that time. I called the local ambulance, they gave wait time of 45minutes, and then I called 911. The standing orders are on the right side of the POS and as a general nursing practice I knew that I had to give [MEDICATION NAME] for [DIAGNOSES REDACTED], but I didn't see any orders. On [DATE] at 12:45pm, V12 (Primary care Physician) stated If a blood sugar is below 60 or 70, it is critical, resident can present with symptoms of sweating, cold clammy skin, nausea, vomiting and loss of consciousness sometimes. The management of [DIAGNOSES REDACTED] is to give orange juice if awake, if unresponsive either IM [MEDICATION NAME] or IV 50% [MEDICATION NAME] is given or whatever the facility's protocol calls for. The nurses should have given [MEDICATION NAME] by following the standing orders. Standing order means you give it, you don't wait for the physician's call. If the facility had a policy or protocol they should have followed it. Not treating the [DIAGNOSES REDACTED] in the right time can possibly result in damage to brain and kidneys. As for my residents any order that is on the chart or POS is applicable to that particular resident unless it's discontinued. On [DATE] at 2:05pm, V13 (Physician On call) stated I never got paged or received any phone call from the facility regarding this resident's (R1's) [DIAGNOSES REDACTED]. On [DATE] around 1:20am, I spoke to the nurse (V11) regarding another resident but not this resident (R1). It's a general practice to give [MEDICATION NAME] injection to treat [DIAGNOSES REDACTED] and send the resident out to ER. If they can't reach me or hear from me, I would expect them to follow the facility's policy and follow the standing orders using clinical nursing judgment. Facility's policy titled Nursing care of the resident with Diabetes Mellitus reads: purpose is to prevent [DIAGNOSES REDACTED]. Signs and symptoms of [DIAGNOSES REDACTED] include: pale, cool, moist skin, excessive perspiration, stupor, unconsciousness, convulsions and coma. Management of [DIAGNOSES REDACTED]: 4. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] (less than 70mg/dl or less than the physician-ordered parameter): a. Immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or intravenous 50 percent [MEDICATION NAME], per facility protocol and notify the physician for further orders; b. If resident remains unresponsive, call 911 (in accordance with resident's advance directives). Facility's policy titled Standing Orders reads: Certain self-limited conditions that occur frequently are often amenable to treatment with non-prescription medications, using nursing judgment. To facilitate prompt treatment of [REDACTED]. If the Attending physician does not desire standing orders to be utilized, this notation will be made on the clinical record. Facility's policy titled Notification of resident change in condition policy reads: A licensed nurse shall promptly inform a significant change in the resident's physical, mental or psychosocial status, deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications. 2. The licensed nurse is to use professional judgment in determining changes in condition based on assessment and findings or signs and symptoms of change which could lead to deterioration if not treated. Following the assessment, observing signs and symptoms, and obtaining vital signs, the attending physician and family will be promptly notified of significant findings. 8. In the event the physician cannot be reached or does not respond and the resident requires medical intervention or there are clinical complications in the judgment of the nurse, the alternate physician will be promptly contacted. During the interim, appropriate nursing intervention and monitoring measures will be performed and documented. If the attending and the alternate physician cannot be reached, the Director of Nursing or designee will be notified, and contact made with the Medical Director as necessary. 10. In the event the situation is emergency and the nurse cannot reach a physician, and there is a perceived life-threatening situation, emergency care measures will be provided by licensed nurse arrangements made to transfer the resident to the hospital.

Based on interview and record review the facility failed to prevent an abusive incident of a staff member pushing one (R1) of four residents reviewed for abuse. This failure resulted in R1 being pushed into her own feces, becoming fearful and causing chest pain that resulted in R1 being transported to the hospital and admitted for chest pain. Findings include: R1 is a [AGE] year old woman who was admitted on [DATE] from an acute care hospital to a skilled nursing home and rehabilitation center with the admitting [DIAGNOSES REDACTED]. R1 Minimum Data Set ((MDS) dated [DATE] reads she requires two person assistance with hygiene, bathing, dressing, and range-of-motion limits for lower extremities. R1 is alert, oriented to person, place and surrounding with cognitive Brief Interview for Mental Status (BIMS) score of 15. On 08/01/17 at 1:02 PM E25 (Director of Social Services) stated, It all happened early in the morning. I listened to R1's initial allegation while I spoke with her during her stay at the hospital. R1 stated that she was handled inappropriately by a staff from our facility. I noticed the bruises on her right upper arm underside that extended from below the right thumb up to the armpit. I also remember seeing some bruises near the right eye and right lower extremities. R1 developed chest pain after the incident and was transferred to the hospital. E25 (Director of Social Services) also stated, Yes, I really feel sorry for the resident. And from talking with R1 at the hospital I know R1 was very scared, jittery, and repeatedly saying the incident to me and to the staff at the hospital. It was definite that R1 was inappropriately handled by the night staff. But, I am not sure who exactly to pinpoint. R1 was giving me descriptions of different staff each time I spoke with her. But her story remained the same as - someone had pushed her into the feces and asked her to clean it up herself. On 08/02/17 at 12:58 PM, E2 (Chief Operating Officer) stated, We have completed the abuse investigation regarding R1s allegation. The facility is siding with the resident allegation and we have terminated an employee. On 08/03/17 at 11:45 AM, E6 (Director of Nursing) stated, It was the second day of my employment with the facility when the investigation was conducted. I was not here in the facility when the incident occurred. Yes, R1 was taken to the hospital with complaint of chest pain. R1 made the allegation of abuse, and that she was made to clean her own mess. R1 kept repeating the same scenario with different employee names. I know the incident happened, but we are unable to get a get a clear picture of who did what. On 08/01/17 at 11:00 AM, E2 (Chief Operating Officer) presented the Reportable Incidents Log of the facility. The record review reads, The incident investigation beginning on 05/04/17 at 9:44 AM with the initial allegation from R1's family member. A thorough investigation was conducted by the facility into the matter. Due to the new description provided by R1 to the local detective officer, two staffs on night shift were suspended pending investigation. Further interview with R1 revealed that incident occurred between 2:00 - 3:00 AM on 05/04/17. R1 was consistent with the time of the incident and what had occurred during the time of the alleged incident. Per the camera footage, the alleged perpetrator was terminated. And, the final report was faxed to the Public Health office on 05/08/17 at 6:51 PM. On 08/02/17 at 10:30 AM, E2 (Chief Operating Officer) presented the facility policy on Abuse Prevention Program dated 11/2016 that reads as follows, establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. On 08/03/17 at 12:15 PM, E6 (Director of Nursing) stated, We provided in-service and training to all our employees. We have also included abuse training to our orientation packet. We did not make any changes to the policy. Our director of social services spoke with all the residents and made sure they are all safe. On 08/03/17 at 12:50 PM, E25 (Director of Social Services) stated, It is important to make sure that all the residents are safe in the facility. I went into each resident room and spoke with them. I spoke with all the residents on the fourth floor. On 08/02/17 at 3:15 PM, Z4 (Social Worker, Acute Care Hospital) stated, R1 was bought to our emergency room via ambulance with complaints of chest pain at the nursing home. R1 stated that she was arguing with a staff and developed chest pain. Her right arm was black, blue and red. When I saw her on 05/07/17 it was getting better. R1 said that someone had abused her at the nursing home. On 08/02/17 as part of the record review the pictures of the bruises of R1 that shows black, blue and red bruises on her right eye, right upper arm, right flank region, and right leg around the knee joint. On 08/03/17 at Acute Care Hospital faxed R1's emergency room admission records. R1's face sheet reads that she was admitted with the [DIAGNOSES REDACTED]. Further, the physician documentation dated 05/04/17 at 14:52 reads: R1 developed right upper extremity [MEDICAL CONDITION] and had ultrasound done which were negative. R1's daughter noted loose stool on some of R1's clothes that she picked up from the facility. The emergency room history and physical notes from the physician reads that R1 has bruising of right upper arm from elbow to the triceps. And bruises found on the right flank.

Based on observation, interview, and record review, the facility failed to develop and implement a plan of care with nursing interventions to reduce or prevent the development of new pressure sore for 1 (R10) of 3 residents reviewed for pressure ulcer in a sample of 27 residents. This failure resulted in R10 acquiring new pressure sores progressing to stage 4. Findings include: Medical record for R10 document he was [AGE] years old admitted to facility on 8/2/2013 with [DIAGNOSES REDACTED]. According to MDS, R10 requires total assistance from two staff members for bed mobility and transfers. R10's bilateral legs are contracted. On 8/1/2017 at 7:15AM, R10 laid in bed. His upper torso faced left and his buttock was on back but more to left side. E13 (Certified Nursing Assistant/CNA) checked him for incontinence. His under-pad had some discoloration as leakage. The dressing on the wound was halfway on the wound and the entire buttock was fiery red. E13 said R10 should not have been left like that. On 8/1/2017 at 10:50AM, R10 laid in bed with his upper torso towards the left. His lower torso was almost flat on bed with pressure slightly off the right buttock. He watched television situated to his left visual radius. R10 was alert and aware of his surroundings. R10 said, I like to be on this side as I can eat on this side (pointing to left side) and watch TV. On 8/2/2017 at 6:55AM, E10 laid in bed on his back but inclined to left side. His dressing on his sacral wound was half way off and part of the wound was exposed. His incontinent pad was spotted with old and fresh discoloration. E28 (CNA) said that although R10 had a [MEDICAL CONDITION] and an indwelling catheter, he still urinated and had bowel movements. She said he should not have been left like that. On 8/2/2017 at 8:55AM, R10 said no one checked on him all night and he was up watching television. According to Dietician monthly notes and wound care weekly notes the following noted a history of R10's wounds. On 8/2/2013, R10 was admitted with one stage 4 pressure on sacrum. No measurements obtained. In February of 2014, wound report documented R10 acquired a new wound on left anterior shoulder that measured 2.6cm x 3.5cm. Sacral ulcer stage 4 on left lateral buttocks measured 7.0cm x10.0cm: In April 2014, wound assessment noted the following for R10: Lower sacrum stage 4 pressure ulcer measured 0.5cm x 0.6cm; left lateral buttocks Stage 2 measured 8.0cm x 10.0cm; left medial buttock started on 3/18/2014 as a Stage 3 measured 3.0cm x 1.1cm. Bilateral legs with venous ulcers. In September 2014, R10 was recorded with pressure ulcers on: Lower sacrum Stage 2 measured 8.5cm x 1.5 cm x 0.1cm. Left anterior shoulder un-staged measured 2.8cm x 2.5cm. Left anterior leg with a pressure ulcer measured 10.0cm x 6.5cm. Left lateral buttock was noted with a stage 2 that measured 10.5cm x 2.5cm. Left anterior shoulder was noted with wound un-staged by facility. It measured 3.7cm. X 3.8cm. A review of the weekly wound report for R10 dated 7/25/2017 noted the following: Stage 4 sacrum pressure ulcer that measured 6.5cm x 7.3cm x 1.5cm. There were un-staged wounds noted by the facility on left buttock that measured 14.5cm x 4.0cm x 0.2cm; left lower back that measured 3.0cm x 2.0; left anterior shoulder that measured 1.2cm x 1.5 cm x 0.1cm; left lateral leg that measured 10.0cm x 3.0cm x 0.1cm. On 8/2/2017 at 9:50AM, wound treatment to R10's wounds included sacral area - left and right buttocks. There was a new wound (stage 2) on right buttock which measured 2.6 centimeters (cm) x 1.8cm. Surrounding area was extremely reddened. Largest wound on left sacral area noted to be 14cm x 3cm (Stage 4). Facility did not present Skin assessment for R10. Laboratory values were done and reviewed by Physician and Dietician. Notes from dietician dated 7/27/2017 noted, Diet and supplement remain appropriate to support estimated needs for wound healing at this time. According to documentation, R10's weight in May was 117.9 pounds and in July 2017 his weight was 125 pounds. Pressure ulcer report documented a total of 10 new acquired wounds in the past two months in facility. On 8/3/2017 at 11:05AM R10 was noted on his left side in bed until 1:15PM continuously without being repositioned. At 1:15PM, staff brought his lunch tray. R10 eats while on his left side. E31 (Assigned CNA) said she was on lunch. On 8/3/2017 at 1:20PM, E5 (Assistant Director of Nursing, ADON) said residents were supposed to be repositioned in bed every two hours if they could not do it themselves. On 8/4/2017 at 8:45AM, Z2 (Physician) said even though R10 had a [MEDICAL CONDITION] bag and a urinary catheter, he still had normal functions in those areas. She said some reasons for pressure ulcers included incontinence and pressure on the area for long periods and she clarified to say pressure for more than 30minutes. Z2 was informed of the state R10 was in on 8/2/2017 and she said, He should not have been left like that. Z2 said residents who cannot help themselves should be repositioned at least every two hours. Facility's undated policy on pressure ulcer documented, Pressure ulcers are often made worse by continual pressure, heat, and moisture.

Based on observation, interview and record review, the facility failed to follow their policy and implement fall interventions from the care plan to prevent falls for 2 of 6 residents (R1, R2) reviewed for falls in the sample of 7. This failure resulted in R1 being left unsupervised in the hallway, falling out of the wheelchair, and sustaining a fractured left nasal bone. Findings include: On 2/18/15 at 6:15am, four residents were lined up in wheelchairs against the wall across from room 102. E8 (Nurse) was standing behind the desk as the nurse's station, out of line of site of the four residents. E8 heard a moaning sound, leaned forward across the desk, and saw R2 on the floor in front of the wheelchair. The alarm was not activated. R2 sat on the floor with the chair alarm clipped to her sweatshirt, the cord was slack and extended all the way to the alarm box. The tab did not pull away from the box, therefore, the alarm was not activated. At 6:30am, E8 stated the cord was too long and should have been shortened when R2 was up in the wheelchair. Closed record documents R1 was admitted to the facility on [DATE], and transferred to the hospital on [DATE] after a fall. Mainstreet 24 Hour Report Sheet 2/5/15 documents R1 was in a wheelchair in the hallway, then fell on the floor face down while trying to get out of the wheelchair. R1 was bleeding from the nose and there was a hematoma on the left side of the face. R1's assigned aide was alerted by another aide, first aid was administered, family and physician were called, R1 was transferred to the hospital. E9 (Nurse) was in another room passing medications. Fall Care Plan documents R1 slid from the wheelchair on 10/8/14, 11/14/14, 12/3/14, 12/26/14, 1/30/15, and 2/5/15. Interventions include structured location monitoring and explain safety concerns 8/9/14, frequent monitoring 9/10/14, anticipate needs and provide assistance to prevent falls 10/12/14, and place at nurses station for monitoring 10/8/14. Minimum Data Set (MDS) 2/1/15 Section C Cognitive Patterns scores R1 8 out of 15, indicating moderate cognitive impairment. R1 is assessed as having inattention and disorganized thinking; difficulty focusing attention, easily distracted, difficulty following what was said, irrelevant conversation, unclear flow of ideas. Section G Functional Status assesses R1 as needing extensive assistance with one person physical assist for transfers, is not steady and only able to stabilize self with assistance from another person during standing from a seated position. Section J Health Conditions documents R1 has had 4 falls since the last MDS Assessment on 11/7/14. Incident Report 2/5/15 documents R1 fell to the floor face down from the wheelchair, swelling noted to the left side of the face, physician was notified, and R1 was transferred to the hospital. Hospital record documents R1 was sent to the emergency room after a fall from the wheelchair. R1 has a hematoma to the left side of the head, swelling around the left eye, and a cut to the lower lip. X-ray and Computer Tomography 2/5/15 document R1 has a fractured left nasal bone. On 2/18/15 at 6:10am, E5 (Nurse Aide) stated on 2/5/15 around 5am, R1 was up in the wheelchair and placed in the hallway. R1 kept standing up from and leaning forward in the wheelchair, activating the chair alarm. While E5 was in another room, an alarm sounded, E5 looked out of the room, and saw R1 on the floor bleeding. E5 called for help. E5 stated R1 was very confused and cries. On 2/18/15 at 7am, E6 (Nurse Aide) stated she got R1 up first on 2/5/15 around 5am. E6 sat R1 in the wheelchair in the hallway, then went to get other residents up out of bed. E6 stated R1 did not like getting up that early but her name is on the list to get up on the night shift. R1 was falling asleep that morning while E6 tried to get her dressed and out of bed. E6 stated an alarm was activated, other staff called for E6. When E6 came out of another room, R1 was on the floor in the hallway bleeding. E6 stated R1 was agitated. On 2/18/15 at 7:50am, E2 (Director of Nursing) stated R1 would slide herself to the edge of the wheelchair and fall out, it was a behavior of R1. On 2/5/15, R1 fell out of the wheelchair, hitting her face on the tile floor. Staff get residents up on the night shift. Sometimes there is not anyone at the nurse's station because everyone is busy getting other residents out of bed. R1's "get up time" was adjusted to get her up last. On 2/18/15 at 8:05am, E7 (Restorative) stated R1 had behaviors of sliding out of the wheelchair. On 2/18/15 at 11:30am, E3 (Assistant Director of Nursing) stated residents are brought to the nurse's station so staff can "keep an eye on them." A staff member is around or near the nurse's station and can see the residents that are sitting there. On 2/18/14 at 1:50pm, E1 (Administrator) stated the cord on R2's chair alarm should have been shortened when sitting up in the wheelchair. On 2/18/15 at 3:20pm, E9 (Nurse) stated she was in another room passing medications when she heard an alarm. E9 came out into the hallway and saw R1 on the floor. R1 had a hematoma on the left side of her face and was bleeding from the nose. E9 stated R1 is agitated and cries all the time. On 2/19/15 at 10:30am by phone, Z1 (Physician) stated if all 3 staff members stated they were not at the nurse's station watching R1, then all 3 are responsible for leaving R1 alone in the hallway, not watching R1, and she fell . Fall Prevention and Restorative Nursing - the focus of the care plan should be to address the underlying cause or causes of the resident's falls, or if the resident has not sustained a fall, the factors that place him or her at risk for falling. Fall Incidents - If a resident is noted attempting to get up from wheelchair, intervene to assist to sit back down to prevent fall incident.

Based on observation, interview and record review, the facility failed to have preventive interventions in place for a resident at risk for pressure ulcer and follow physician's treatment order for a pressure ulcer site for one of four sampled residents (R6) reviewed for the care and service for pressure ulcer, in a sample of 18. As a result of these failures, R6 acquired two pressure ulcers. Findings include: R6 is a [AGE] year old admitted to the facility on [DATE] with Type I diabetes, hypertension, [MEDICAL CONDITION] disease, [MEDICAL CONDITION] and [MEDICAL CONDITION]. R6 was admitted to the facility on [DATE] with no pressure ulcers according to the nursing notes dated 11/4/13. R6's [MEDICATION NAME] level on 11/6/13 was 2.8 normal range (3.3 - 5.2). R6's Braden Scale for Predicting Pressure Sore Risk dated 11/11/13, 11/18/13 and 11/25/13 scored 15. The score key for the Braden Scale is 15-18 = Mild Risk. R6's admission MDS (Minimum Data Sheet) dated 11/11/13 documents that R6 is at risk for developing pressure ulcers. R6's admission care plan dated 11/4/13 under pressure sores/skin care does not have the preventative measures checked.. The goal of the pressure sore/skin care admission care plan stated "Prevent/heal pressure sores and skin breakdown." R6's POS (Physician order [REDACTED].(left) Ischium. L Ischium: Cleanse with NSS (Normal Sterile Saline), Pat Dry Apply mupirocin, silver absorbing gel, [MEDICATION NAME] with dry dressing. On 1/8/14 at 9:30am during a wound dressing change, the surveyor observed R6 with a facility acquired Stage 4 pressure ulcer on her left ischium measuring 6.5 centimeters in length and 4.5 centimeters in width and 1.5 centimeters in depth and an acquired unstageable pressure ulcer on her right heel measuring 5 centimeters in length and 4.5 centimeters in width. During this time the surveyor observed, E7 changing R6's left ischium pressure ulcer dressing. E7(Wound Nurse) did not follow the doctor's order for the treatment. E7 packed R6's left ischium wound with calcium alginate. According to the physician's orders [REDACTED]. On 1/8/14 at 10:50 am, the surveyor asked E7 why did she used the calcium alginate on R6's left ischium wound when the calcium alginate was discontinued. E7 stated that the pharmacist said it was ok. R6's nursing notes on 11/4/13 at 5:16pm reads "No pressure ulcers." On 11/4/13 at 5:59pm, R6's nursing notes state "Walks occasionally." R6's Skin Monitoring: Comprehensive CNA Shower Review on 12/18/13 documents redness. R6's nursing notes on 12/19/13 at 3:38pm "Acquired wound left ischium 4.5 centimeters in length, 3.2 centimetes in width and 60% necrotic. Acquired wound coccyx 2.5 centimeters in length and 3.0 centimeters in width. R6's nursing notes on 1/7/14 at 4:26pm reads left ischium stage 4 pressure ulcer measured 5.2 centimeters in length, 4 centimeters in width, 1.5 centimeters in depth, 60% necrotic, 40% granulation. Z2(Attending Physician) was interviewed on 1/9/14 at 10 am regarding R6's facility acquired Stage 4 left ischium pressure ulcer and unstageable pressure ulcer on R6's right heel. Z2 stated that she was aware of the pressure ulcers. Z2 was asked how she thought the pressure ulcers developed. Z2 stated that it has a lot to do with the frequency of positioning. Z2 stated that R6 may not have developed unstageable pressure ulcers. The facility's Pressure Ulcer Prevention policy reads the purpose is "To prevent skin breakdown and development of pressure sores."

Based on interview and record review, the facility failed to follow their clinical alarms policy by failing to apply a bed alarm for one resident (R16) out of three residents reviewed for falls. This failure resulted in R16 sustaining a right hip fracture and the facility failed to follow their elopement policy/procedure for one resident (R12) of three residents reviewed for elopement risk. This failure resulted in R12 leaving the facility unsupervised. Findings Include: 1. Review of facility ' s clinical alarm policy denotes Purpose: To provide intervention for residents at increased risk for falls and decreased cognition related to their own safety. Policy: When a resident has experienced one or more falls a clinical alarm such as a chair, personal, and/or bed alarm may be used as an intervention to assist in decreasing and/or preventing future falls. The alarm will remain in place indefinitely, or until deemed no longer necessary for that specific resident. The Director of Nursing and/or designee will routinely check alarms for proper function and/or placement. R16 care area assessment summary dated 4-13-13 denotes care area triggered falls: wandering occurs, R16 requires assist x1 with transfer. R16 has unsteady gait and balance. R16 fall risk assessment dated [DATE] denotes score of 18; score above 10 represents high risk. R16's fall prevention care plan denotes 4-30-13 R16 got up from wheelchair lost balance and fell on her back, no apparent injuries. 5-9-13 R16 slid out of her wheelchair no apparent injuries. R16's fall prevention care plan dated 7-11-13 denotes R16 will have no fall thru next review; intervention bed alarm, chair alarm and place near nurses station. R16's nurse note dated 7-19-13 at 1:45 AM, R16 was noted lying on the floor on her right side, head to toe assessment R16 verbalized no complaints nor concerns and doctor notified. R16 nurse notes dated 7-19-13 at 12:36 PM, denotes R16 complained of pain when right leg is moved, yells out and guards leg. Medical Doctor called and given orders to send to hospital. R16 ' s hospital X-ray dated 7-19-13 denotes " Findings: There is a subacute fracture neck of femur with some impaction. Impression: Subcapital fracture, neck of right femur with impaction. Interview with Z2 ( Medical Doctor) on 8-15-13 at 10:50 AM," R16 ' s hospital X-ray results revealed that she did fracture her right hip and that one of the bones impacted into the other. With this injury, R16 had to have stood up and fell . If the facility had assessed R16's need for a bed alarm ; it would have been helpful to have utilized it. Because R16 is confused, the bed alarm would have at least notified staff that she was trying to get out the bed." Interview with E12 (Licensed Practical Nurse) on 8-14-13 at 4:30 PM," During the early morning on 7/19/13,I heard some noise from R16's room. I got up from the nursing station and went to R16's ' room and saw her on the floor. I did not see a bed alarm. I did not know R16 was supposed to have a bed alarm. Interview with E11 (Certified Nurse Aide) on 8-14-13 at 1:40 PM," on 7-19-13, E12 called me from R16's ' room and when I got there, E12 told me that she heard R16 fall. I saw R16 on the middle of the floor. I did not see a bed alarm on her bed." Interview with E2 (Director of Nursing) on 8-15-13 at 11:20 AM," Restorative nurses assessed R16 to need the bed alarm. The restorative nurse was supposed to get the alarm from storage and place it on R16' bed; then restorative was to let nursing know R16 needed a bed alarm. It was not communicated to nursing that R16 needed a bed alarm nor that R16 care plan was updated with new intervention; the bed alarm." Findings include: 2. R12 is [AGE] years old with a [DIAGNOSES REDACTED]. From the day of admission, R12 has been documented to attempt to elope from the facility. R12 is alert, very confused and ambulates independently. The comprehensive care plan dated 6/5/13, noted that prior to admission, R12 had a history of [REDACTED]. On the 2nd day of admission, the evening nurse documented that R12 made an elopement attempt; staff to monitor closely. On the 3rd day of admission, another nurse documented that R12 was up most of the night, trying to go home ; that night, R12 was noted walking down the hall, dragging buckets filled with belongings. Two weeks later, a nurse documented on 7/23/13 that R12 exited the building through the employee break room exit at 7:44 AM. On 8/01/13 at 11:00 AM, E11, Administrator stated that when a resident is assessed to be of high risk for elopement, the resident is assigned 1:1 monitoring by a CNA (Certified Nurse Aide). Review of the facility policy and procedure for high risk for elopement residents stated, in part: When a resident displays escalating behaviors, the Charge Nurse immediately places the resident on high risk protocol, and notifies the Director of Nursing.The Charge Nurse will assign an observation staff member. The assigned CNA (Certified Nurse Aide) must make visual contact with that resident every 15 minutes, and must respond to all door alarms that sound. Assign another CNA to monitor during the primary aide's breaks and lunch. Review of the visual contact records showed that visual monitoring did not begin until 7/23/13, the date of R12's elopement. On 8/01/13, 11:00 AM, E1 stated that on the day that R12 eloped, R12 had a 1:1 monitoring CNA. The CNA went to lunch after reporting off to the Charge Nurse. When the nurse heard the door alarm, the nurse went to the door and closed the door, never looking out or going out to look for R2. E1 stated that had the nurse stepped through the door, R12 would have been seen. As a result, R12 continued out beyond the grounds of the facility which is bordered by very busy, heavy vehicle trafficked major streets. Someone took R12 to the fire department and finally the police department. On 8/01/13, 11:00 AM, R1 stated that the facility sits on 7 acres of land. Review of the facility policy and procedure for when a door alarm sounds: When any door alarm sounds the facility staff shall: Check the exit door for any exiting resident by means of a visual check. Visual check means observing the area around the exit, and may require leaving the building. On 8/01/13, 1:30 PM, E18, Director of Maintenance stated that all exits, except for the main entrance, were alarmed and had to be cleared by staff using a key pad code. While observing the exits from the building on 8/01/13, along with E18, It was noted that 7 of the 11 alarmed exits did not function as stated. The southeast door to exit the building did not have an alarm. E18 stated that the alarm was not needed because that door was protected by administrative office door which was alarmed. However, E18 agreed that the office door alarm was not set until office staff left sometime in the evening.

A. Based on record review and interview the facility failed to provide adequate supervision and failed to develop a plan of care to decrease the risk of falls for 2 of 3 residents (R24, R26) involved in fall incidents, and identified to be at risk for falls. R24 was placed in bed for incontinence care, and was observed by staff rolling out of bed to the floor which resulted in R24 being admitted to hospital with a non-displaced fracture. Findings include: 1). According to the facility's incident report dated 7/13/11 9:00am denotes that R24 was placed in bed to be changed and was observed rolling from the bed to floor, on onto the floor mat The follow up indicates that on 7/13/11 at 3:00pm x-ray obtained of left wrist. According to R24's nurses notes dated 7/13/11 at 9:54am denotes that R24 was involved in a fall incident observed on the floor, noting no apparent injury noted. Nursing note 9:50 indicates that R24 was placed in bed to be changed, observed rolling to the floor onto low mat, R24 was noted as being assisted back to bed. R24 was noted to be assessed for injury and none noted, however R24 is noted as grimacing with range of motion to the upper left extremity. On 9/22/11 at 2:30pm E7 (nurse), said that she observed R24 on the floor, but said that certified nurse aid observed R24 rolling onto the floor. E7 was unable to verbalize which certified nurse aide observed R24 rolling to the floor. E7 said that after R24 was assisted back to bed, E7 said that she conducted a body check, and nothing was found. E7 said that however when R24's left upper extremity wrist area as touched R24 grimaced in pain. E7 said that she notified the physician and the attending physician ordered an x-ray of the left wrist. According to R24's clinical record nursing notes dated 7/13/11 there was no description and/or assessment of R24's left upper extremity in the nurse note. According to the nurse notes dated 7/14/11 10:50am indicates raised bruising to R24's left hand bruising to left hand. Nurse note 7/14/11, 11:22am indicates Xray results to left hand no dislocation or fracture. According to the nurse notes 7/14/11 through 7/18/11 R24's left wrist continued to swell with bruising noted. On 7/18/11 R24 was sent to the hospital for evaluation of swelling and bruising to the left wrist. On 9/22/11 at 2:30pm E7 said that she didn't recall any swelling or bruising, to R24's left upper extremity, E7 said that she couldn't recall whether R24's left wrist range of motion was within normal limits. E7 said she couldn't remember what happened that day 7/13/11. E7 reviewed the nursing notes and incident report, and was unable to verbalize to the survey team the description of R24's left wrist after the fall. According to the hospital record dated 7/18/11 x-ray of the left forearm impression indicates equivocal findngs of acute undisplaced fracture at the proximal shaft of the radius. Marked soft tissue swelling posterior to the wrist and distal forearm compatible with hematoma. According to R24's clinical record fall risk assessment dated [DATE] R24 was identified to be at risk for falls, R24 scored a 12, (10 or greater = high risk for falls). There was no new fall risk assessment noted in R24's clinical record after R24 was observed falling from bed on 7/13/11. According to R24's most current care plan indicates R24 is at risk for future falls, the plan of care was dated 3/7/11, there was no quarterly review date and no review or new interventions after R24's fall on 7/13/11. On 9/22/11 at 12:15pm E3 (director of nursing), said that fall risk assessment are immediately completed after residents are involved fall incidents. According to the fall policy and procedure, denotes if a resident is involved in a fall the resident will have a care initiated and interventions will be put into place. The facility star program indicates any resident who experiences a fall will placed on the star program, to alert staff and increase awareness toward residents. The program includes a care plan initiated with interventions. According to the facility's fall prevention program the risk assessment is the first step to determine the risk, and a resident is involved in a fall a post fall risk assessment must be done to determine the cause of the fall. 2). According to the facility's accident / incident reports the R26 was involved in a fall incident on 8/13/11 9:55pm denotes R26 lost her balance while trying to sit down in chair and fell . R26 was assessed with [REDACTED]. According to R26's nursing notes there was no entry noted with an assessment, status or physician notification of R26's fall on 8/13/11. Nursing note 8/14/11 7:01pm indicates day 2 of 3 post fall, denotes R26 lost her balance when trying to sit in chair and fell , the note also indicates that physician was notified 22 hours after R26's fall incident. According to R26's fall risk assessment dated [DATE] indicates that R26 was assessed with [REDACTED].=high risk). R26's next documented fall risk assessment was completed on 9/811. There was no fall risk assessment found after R26's fall incident of 8/13/11. According to R26s current care plan dated 9/6/11 there was not plan of care in R26's clinical record addressing R26's high risk for falls, no plan of care identifying R26 was involved in a fall on 8/13/11, and no interventions implemented and /or noted to decrease R26's fall risk. On 9/22/11 R26's care plan was reviewed with E3 (director of nursing), and E3 said that the plan of care reviewed was R26's most recent plan of care dated 9/6/11. According to the facility's accident and incident reports dated 8/20/11 R26 was observed coming from another residents room and tripped in the doorway and fell face first striking forehead on the floor, causing moderate bleeding without loss of consciousness. R26 was assessed, the physician was notified and R26 was sent out to the hospital for evaluation, R26 was noted as returning to the facility with a [DIAGNOSES REDACTED]. According to R26's clinical record there was no fall risk assessment completed post R26's fall incident on 8/20/11, and no care plan developed with interventions to reduce R26's risk of falling after R26's second fall incident dated 8/20/11. On 9/22/11 at 12:15pm E3 said that fall risk assessment are immediatley completed after residents are involved fall incidents. According to the fall policy and procedure, denotes if a resident is involved in a fall the resident will have a care initiated and interventions will be put into place. The facility star program indicates any resident who experiences a fall will placed on the star program, to alert staff and increase awareness toward residents. The program includes a care plan initiated with interventions. According to the facility's fall prevention program the risk assessment is the first step to ddetermine the risk, and a resident is involved in a fall a post fall risk assessment must be done to determine the cause of the fall. B) Based on observation and interview facility failed to remove side rail from the floor of one resident (R7) out of six residents assessed for falls from a sample size of 30 residents. Findings Include: Interview with E5(Assistant Director of Nursing/Wound Nurse) on 11-29-11 at 10:15 AM, states R7 is blind. During initial tour with E5 on 11-29-11 at 10:15 AM, observed full length side rail with brackets connected to both ends on the floor between the wall , dresser and R7's bed. Interview with E5 at 10:15 AM on 11-29-11 states side rail should not be on the floor. E5 states she not sure who placed the side rail on the floor. Interview with E4 (Maintenance Supervisor) on 11-29-11 at 10:17 AM, states the side rail should have been in the basement after it was removed, not on the floor. E4 states he did know who took the side rail off and put it on the floor. Record review of R7's physician's orders [REDACTED]. Record review of R7's Minimum Data Set Section B1000: Vision is coded #4; severely impaired- no vision or sees only light, colors or shapes; eyes do not appear to follow objects.

Based on record review and interview, the facility to ensure that resident's are free from falls and injury for 2 of 9 sampled residents (R2 and R3) R2 sustained a left arm fracture and R3 sustained a fracture to the right distal clavicle. Findings include: R2 fell 4 times within 4 months, (from 03/23/10 to 07/19/10), with one of the falls resulted in an injury to the posterior left upper arm that sent the resident to the hospital. And R3 has had 12 incidents of falls (from 02/10/10 to 02/14/11), some with minor injuries, but, 9 of these falls occurred within a 6 month period of time (from 08/4/10 to 02/14/11). One of them, on 09/14/10, is an injury of unknown injury whereas the resident sustained [REDACTED]. - R2 is a [AGE] year old with [DIAGNOSES REDACTED]. On 03/29/11 at 12:40pm, surveyor interviewed R2 about falling. R2 states "I (R2) fell about 3 or 4 times. One time I (R2) was in the bed trying to get up, and I (R2) fell . When I (R2) fell and went to the hospital, I (R2) don't remember getting stitches. About 5 or 6 in the early morning, I (R2) fell out of bed. Some nurses got me (R2) up and put me (R2) in the ambulance, that's all I (R2) remember." R2's Minimum Data Set ((MDS) dated [DATE], 04/16/2010 and 05/10/2010 depicts the resident have cognitive impairment, with short term memory loss, requires assistance from staff with transferring (moving between surfaces), with toileting and has declined from walking with supervision to extensive assistance needed, and is occasionally incontinent of bowel and bladder. The incident reports and nurses notes indicate the following fall history: 03/23/10 at 11:53am, found on the floor in bathroom, unwitnessed, no injury; 04/15/10 at 6:30am, found on floor in bathroom, unwitnessed, no injury; 07/03/10 at 8:40pm, found sitting on floor at bedside, unwitnessed; and 16 days later on 07/19/10 at 6:30am, unwitnessed, although there is name listed as being an involved party. The nurses notes dated 07/19/10 7:51am states, as written in part, "CNA (nurses aid) reported to writer that resident (R2) had fallen upon entering patient room. Approximately 3.5 x 4.5 cm cut noted on upper posterior of left arm with moderate amount of bleeding." Physician called and R2 sent to the hospital for treatment. The resident returned the same day at 3:34pm with several stitches to the left upper arm, according to the nurses notes. Returned to the facility with 10 sutures, according to the "Report of Incident/Accident" report signed by E2 (nurse). On 03/30/11 at 9:40am, E7 (care plan) questioned about the care plan. E7 states, "I (E7) started at nursing home on October 18, 2010 and am not responsible for missing care plan documentation for July 2010." Telephone interview with E2 on 04/21/11 at 1:10pm about R2's falls and subsequent injury. E2 states, "R2 does not like to call for help. R2 gets up and go to the bathroom, that's why R2 falls. We care planned R2 over and over, R2 believes she (R2) can walk and take care of self. Most of R2's falls are in the middle of the night." Review of R2's care plan depicts the 07/03/10 and 07/19/10 incidents are not addressed. The incidents that are addressed all have the same approaches and goals after each fall. - R3 is [AGE] year old with [DIAGNOSES REDACTED]. Based on a review of incident reports and nurses notes, R3 had a total of 12 fall incidents with 9 of them being within a 6 month period of time as follows: -08/14/10 at 6:10pm, fall, no injury; -08/19/10 at 8:15am, fall, witness no longer work for the facility according to the internal investigation of the incident, no injury; -08/22/10 at 11:15am, fall, unwitnessed, no injury; -08/23/10 at 6:50pm, fall, witnessed, witness no longer work for the facility, no injury; -09/14/10, injury of unknown origin, unwitnessed. The incident report states, "Resident (R3) noted with abnormal Clavicle on right side." A x-ray done immediately (mobile), and the results is "Fracture of the distal clavicle with superior angulation deformity." The resident then sent to the hospital, and sent back to the facility the same day with discharge instructions related to a "fractured clavicle." -10/08/10 at 10:45pm, fall, unwitnessed, resident sustained [REDACTED]. R3 was treated at the facility for this injury. -10/24/10 at 5:00pm, 16 days later another fall, unwitnessed and sustained a bump on top of the head; -01/24/11 at 0530am, fall, unwitnessed, sustained a large lump to the back of the head; and -02/14/11 at 1:45pm, fall, unwitnessed, sustained superficial redness to right knee, per incident report. R3's Minimum Data Set ((MDS) dated [DATE], 09/21/10 and 03/20/2011 depicts has some cognitive impairment, incontinent od bowel and bladder, and requires assistance with ambulation and toileting. The care plan is not updated after fall event. The last date a problem of a fall was documented is 06/23/2010. The 09/14/10 injury of unknown origin is not addressed. Interview with E7 on 03/30/11 at 12:20pm about R3's incidents. E7's written statement, as written in part is, " For injury dated 09/14/10 (incident report) resulting in fracture to right clavicle was not during my (E7's) tour of duty, and I (E7) have no knowledge of incident." On 04/21/11 at 1:10pm, E2 was interviewed about what is being done to minimize R3's fall incidents. E2 states, "R3 has Alzheimer's and Dementia. You ask R3, R3 can never say what happened, R3 has a history of falls. R3 believe R3 can do more than R2 is capable of doing. R3 tries to walk, go to the bathroom unassisted and falls."

Based on observation, interview and record review the facility failed to protect resident from physical mistreatment. A cognitively impaired resident that frequently resists care by striking out while being put to bed was struck in the face by a staff member of the facility, a certified nurse' s assistant(CNA). As a result this resident suffered swelling and bruising to right side eye and cheek area. This failure occurred for 1 out of 3 residents in the sample (R1). Findings include: Clinical record review indicates that R1 is a [AGE] year old female with [DIAGNOSES REDACTED]. R1 was observed in the dining room on 09-08-2010 at . R1 was noted with purple - black bruise under her right eye / cheek area. R1 was again observed on 09-22-10, discoloration had faded and was barely noticeable. Nurse's note dated 08-19-10 at 12:29 AM document incident type: swelling noted to res rt side cheek, and small amt of blood to mouth. Staff involved: CNA. Witnesses: none. Vitals: refused. possible cause: unknown. Time of incident: 11:05 PM. Location: resident 's room. Activity at the time: in bed. Equipment involved: none. Injury: swelling, small amt of blood to mouth. Handwritten note by E11(certified nurse's assistant-CNA) documents..When I came in at 10:30am on 08-18-10 did rounds seen R1 still up. I didn/t see anything wrong with face at that time. I heard E7(licensed practical nurse- LPN) ask E5(certified nurse assistant-CNA) why was R1 still up. She responded she was waiting on E6(CNA) to help her she was tired of getting scratched up....... Incident report dated 08-18-2010 documents resident has sustained injury to right side of face. Resident verbalized "name(s)" of person who allegedly "hit" her. Resident did not have bruising prior to interaction with allegbed offender(s). Section under injuries : Right facial swelling, bruising to Right periorbital area. Interview with R1 on 09-22-2010 at 6:30 PM after supper in the dining room ,she spoke slowly and was not easily understood. Surveyor asked R1 about the bruise under her eye, R1 said it was really horrible, E6(Certified Nurse's assistant-CNA) beat the hell out of me, it hurt, I cried . R1 also said it's happened a long time ago and it's not quite so bad now. Interview with E7(licensed practical nurse on 09-22-2010 at 5:10PM she said that she was sitting at desk, end of shift charting when one of the staff, E10(certified nurse's assistant -CNA) said E7 come and look at R1.She said she went to R1's room and noticed R1 had discoloration (red-green-yellow), slight swelling eye to cheek area. She stated R1 was asked what happened ? She said the" big black monster pounded me in my face." E7 said R1 used her right hand to show closed fist to show how he hit her. She said R1 would not allow her to touch her face. E7 was questioned why the police were not called right away, she responded that R1 did not give a name. However, E7 was aware that E5 was wating for E6 to put R1 to bed. R1 also gave a description of who hit her to E7. Interview with Director of nurses on 09-08-2010, she stated that she went to R1's room and R1 told her that E6 pounded me in my face. A section of Policy on reporting abuse states the administrator , or his designee, will promptly notify the following persons and / or agencies(verbally and written) of such incident: Law Enforcement Officials. There was a lack of a prompt response in calling law enforcement officials, they were not called until over 5 days from the incident.