Every finding on record at Hamden Rehabilitation & Healthcare Center

Based on review of the clinical record, facility policy review and interview for 1 of 3 residents (Resident #16) reviewed for Advanced Directives, the facility failed to ensure the physician's orders accurately reflected the resident/responsible party's documented wishes. The findings include: Resident # 16's diagnosis included heart failure and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 had severe cognitive impairment. A physician's order dated [DATE] directed Full Code status (provide Cardiopulmonary Resuscitation). The care plan dated [DATE] indicated the Advanced Directive code status was Full Code or (Do Not Resuscitate (DNR) and to provide Cardiopulmonary Resuscitation (CPR) or not, based on the responsible party wishes. Resident #16's Advanced Directive Communication Form indicated on [DATE] a conference with the Conservator of Person (COP) indicated not wanting Cardiopulmonary Resuscitation or Do Not Intubation (DNI), and the physician signed the form on [DATE]. A physician's order dated [DATE] directed Do Not Resuscitate (DNR). On [DATE] at 10:29 AM, an interview and clinical record review with the nursing supervisor, Registered Nurse (RN #3) identified the physician's order for Advanced Directives dated [DATE] indicated Do Not Resuscitate (DNR), Resident #16's signed Advanced Directive paperwork which indicated DNR, DNI. RN #3 indicated the paperwork was not transcribed correctly for writing the physician's order and she/he would correct the order immediately. The facility policy labeled Advanced Directives indicated the resident/responsible party's advanced directive wishes will be incorporated into treatment care and services. Once the advanced directive form is completed by the resident or responsible party the physician will sign the form and a physician's order will be obtained.

Based on observations and staff interviews for 1 of 2 residents (Resident #154) reviewed for environment, the facility failed to ensure housekeeping staff reported a soiled privacy curtain for cleaning and replacement. The findings include: An observation on 2/05/2026 at 11:01 AM identified Resident #154's bedside curtain opened fully between the two beds in the room. At the level of the tray table behind the curtain on Resident #154's side an approximate 2-3 feet long and 1-foot-high soiled area noted at the middle of the privacy curtain.An observation on 2/11/2026 at 10:14 AM identified Housekeeper #1 working in Resident #154's room with the door to the room open and the privacy curtain between the beds was still noted to have a soiled area noted on 2/05/2026 at 11:01 AM (6 days ago).Once Housekeeper #1 exited Resident # 154's room on 2/11/2026 at 10:18 AM an interview was attempted. However, she/he indicated the need to contact the housekeeping supervisor and in Spanish asked Houskeeper #2 to do so.An interview and observation on 2/11/2026 at 10:22 AM with the Housekeeping Supervisor indicated privacy curtains are to be removed, replaced with a clean curtain, and the soiled curtains sent to be laundered on a schedule for complete room cleaning called room of the day and daily any soiled curtains are added to a list by the housekeeper on duty, given to the housekeeping supervisor who would have the privacy curtain removed and replaced. The Housekeeping Supervisor provided a handwritten list given to him/her 2 days prior by Housekeeper #1 which indicated resident rooms with privacy curtains needing replacement due to soiled area. Several rooms noted privacy curtains with soiled areas were on the list except Resident #154's. The Housekeeping Supervisor indicated all the privacy curtains on the list and Resident #154's would be changed immediately, and housekeeping staff would be re-educated on the process.

Based on review of the clinical record, review of facility policies and staff interviews for 1 of 4 residents (Resident #103), the facility failed to consistently conduct completed weekly pressure wound assessments that included wound measurements within accordance with facility practice. The findings included: Resident #103 's diagnoses included End-Stage Renal Disease (ESRD), pressure ulcer of the sacral region, gastroparesis, nausea with vomiting, metabolic encephalopathy, type 2 diabetes mellitus with diabetic neuropathy, Peripheral Vascular Disease (PVD), and chronic systolic Congestive Heart Failure (CHF).A Resident Care Plan (RCP) dated 6/11/24 identified Resident #103 was at risk for skin breakdown related to inability to respond to pressure-related discomfort, impaired mobility, bowel and bladder incontinence, and the presence of a wound. Interventions included encouraging frequent repositioning, assisting with repositioning every 2 hours, and using pressure-relieving devices.A quarterly MDS assessment dated [DATE] identified Resident #103 had a Stage 3 pressure ulcer and remained at risk for further skin breakdown, noted pressure-relieving devices and nutritional interventions were in place.A nursing progress note dated 12/14/24 documented Resident #103 returned from a hospital admission with redness noted on her/his coccyx. A subsequent nursing progress note dated 12/16/24 documented the resident returned to the hospital from a specialized treatment due to hypotension and lethargy.The RCP dated 12/19/24 directed weekly wound measurements to the coccyx and treatment as ordered.A nursing progress note dated 12/19/24 documented Resident #103 returned from hospitalization with an open sacral wound measuring 1.5 Centimeter (CM) x 0.5 CM x 0.5 CM.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #103 was severely cognitively impaired; required set-up assistance with eating and oral hygiene; required substantial to maximum assistance with toileting, showering, and dressing; and required partial to moderate assistance with transfers. The MDS further identified the resident was receiving specialized treatment, was at risk for pressure ulcers, and had one unstageable pressure ulcer and noted pressure-relieving devices and treatment interventions in place.The clinical record identified that although nursing staff documented wound treatments frequently, staff failed to complete weekly wound measurements as ordered for 1 of 2 expected weeks in December 2024.A review of the clinical record from January 2025 through November 2025 identified documentation of wound treatment. However, the clinical identified staff failed to document weekly wound measurements as required for the following: 3 of 5 weeks in January 2025, 4 of 4 weeks in February 2025; 4 of 4 weeks in March 2025, 3 of 5 weeks in April 2025, 3 of 4 weeks in May 2025, 2 of 4 weeks in June 2025, 4 of 5 weeks in July 2025, 3 of 4 weeks in August 2025, 3 of 4 weeks in September 2025, 5 of 5 weeks in October 2025 and 2 of 4 weeks in November of 2025.Further review of the clinical record from December 2025 through February 13, 2026, identified staff failed to document weekly wound measurements for: 4 of 4 weeks in December 2025, 5 of 5 weeks in January 2025 and 1 of 2 weeks to date in February 2026.On 2/11/26 at 9:57 AM, the Director of Nursing Services (DNS) identified she/he expects staff to measure resident wounds weekly. The DNS reported that Resident #103 was frequently absent from the facility on Fridays during scheduled wound rounds for her/his specialized treatment appointment. The DNS identified that a registered nurse should complete wound measurements when the resident is absent during wound rounds and indicated she could not identify a reason why the measurements were not completed. The DNS identified licensed nurses have been trained to complete wound measurements.On 2/11/26 at 12:35 PM Licensed Practical Nurse (LPN #3) (wound care nurse) identified wound measurements are expected to be completed weekly during Friday wound rounds. LPN #3 further indicated any licensed nurse performing a dressing change could and should complete wound measurements if they are not completed during wound rounds. LPN #3 further indicated staff received training in completing wound measurements.Review of facility policy, Prevention & Management of Pressure Injuries, directed that pressure injuries are assessed and documented at least weekly and with any significant change until resolved. The policy directed documentation of wound measurements in centimeters (length, width, depth, undermining, and tunneling) and required a weekly RN assessment for all wounds in accordance with policy.The facility failed to ensure that Resident #103 received weekly wound assessments and measurements in accordance with facility practice and policy.

Based on observation of the environment and staff interviews, the facility failed to ensure an electric wheelchair was not obstructing an exit and failed to ensure staff used the appropriate location for charging the electric wheelchair battery per facility practice. The findings include: On 2/05/2026 at 10:35 AM observation identified the facility fire alarm sounding and an electric wheelchair noted parked at the open lounge area at the end of the resident unit hall next to a coffee table. The wheelchair was noted obstructing the facility emergency exit. The electric wheelchair was also noted to be plugged into the wall outlet in the common lounge area, recharging. Further observations identified no attempts by staff to remove the chair were made during the fire alarm. Once the fire alarm ended and it was safe to resume usual duties. An interview with LPN #2 at 10:40 AM indicated the chair belonged to a resident on the unit and must have been placed there by the prior shift. The Maintenance Director arrived at the common lounge area on the unit at 10:42 AM and after surveyor inquiry indicated the electric wheelchair was not allowing egress (a path for exit out of the building). The Maintenance Director further indicated the location and policy procedure for charging electric wheelchairs would have to be taken up by the nursing department, but s/he would have the wheelchair moved immediately. An interview with the Director of Nursing Services (DNS) on 2/10/2026 at 10:10 AM indicated a fire safety policy regarding the exit doors existed but even though a separate room exist for charging electric wheelchairs there was no policy 02/05/2026 10:35 AM fire drill electric w/c obstructing exit and plugged into a common area no residents at this time. pictures taken

Based on clinical record review, facility documents and staff interview for 1 of 3 residents (Residents #71) reviewed for abuse, the facility failed to ensure staff documented clinical findings of the resident's condition for 2 shifts during the 72-hour post fall period. The findings include: Resident #7's diagnoses included Alzheimer's disease, cervical vertebrae fracture and history of back pain. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 as severely cognitively impairment, required partial to moderate assistance with a walker for transfer and ambulation, noted no falls since admission, had a fall in the last month and fall with a fracture in the last 6 months. The care plan dated 5/08/2025 indicated Resident #71 was at risk for falls due to a history of falls weakness impaired mobility and safety awareness. Interventions included: to ensure resident is positioned in the center of the bed during rounds, encourage not to get up alone, ensure resident is wearing nonskid socks, explain all tasks, encourage use of the call bell and to place commonly used items within reach. A progress note dated 8/2/2025 at 10:49 AM indicated the Registered Nurse supervisor was called to the unit and noted Resident #71 lying on his/her right side on the floor, the resident was able to move all extremities without complaints of pain and no injuries noted. The Advanced Practice Registered Nurse (APRN) was notified, and no new orders were obtained at that time. The progress notes dated 8/02/2025at 12:36 PM written by the charge nurse on duty identified Resident #71had an unwitnessed fall reported to him/her at 8:36 AM. The resident was noted on the floor at the entrance to the bathroom verbally denying pain, once the resident was cleared upon standing. The resident complained of some back pain and received Tylenol as scheduled for back pain with some positive effect and the RN supervisor was updated. Vital signs and neurological checks were initiated after the fall and Resident #71 required constant redirection and reminders not to get up on her/his own. A nursing progress note written by the 7-3 PM supervisor on 8/02/2025 at 3:17 PM identified Resident #71 was noted grimacing from pain of the lower right back and hip area and to the left swollen ankle. The APRN was notified with new orders for portable x-rays and noted family member had been updated. A nursing note dated 8/02/2025 at 5:16 PM indicated the x-rays had been completed at 4:45 PM and Resident #71 had tolerated the procedure well. At 9:36 PM results of the left ankle and the lumbo-sacral spine noted osteoarthritis. A nursing progress notes dated 8/02 2026 at 9:40 PM indicated Resident #71 had no signs of discomfort, bedtime care was completed and vital signs, including neurological signs were within normal limits. The next nursing progress note was entered on 8/03/2025 at 8:29 PM (no 11-7 AM shift or 7-3 PM shift notes on 8/03/2025). A nursing progress note dated 8/04/2025 at 4:09 PM indicated it was day 2 post fall and the resident voiced no signs or symptoms of distress or discomfort and appears to be sleeping. The 8/04/2025 Occupational Therapy progress note dated 11:00 AM indicated Resident #71 had been at physical therapy, had difficulty bearing weight when standing, and complained of left hip pain. The note indicated the session was stopped and the supervisor was updated. A nursing note dated 8/04/2025 at 1:10 PM written by the nursing supervisor indicated she/he observed the same complaint upon examination and the APRN was notified and an order for a left hip x-ray was obtained. A nursing note written on 8/04/2025 at 7:47 PM indicated the left hip x-ray results were obtained and noted a left hip fracture. A physician's order from the APRN was obtained to send Resident #71 to the hospital for further evaluation and treatment. A later note written at 8:03 PM indicated the resident left for the hospital at 8:00 PM with 2 ambulance attendants. An interview with the Director of Nursing Services on 2/11/2026 from 10:45 AM through 11:06 AM indicated documentation after a fall should occur every shift for 3 days and the clinical record noted missing documentation which she/he would follow up on. On 2/11/2026 at 12:02 PM identified although the DNS was unable to provide the documentation missing from the clinical record on the 2 shifts for 8/03/2025 for 11-7 AM and the 7-3 PM shift s/he was able to provide the shift-to-shift nursing report sheet (not part of the clinical record) and the neurological documentation sheet including vital signs, neurological and comfort status during the 2 shifts. The facility policy labeled Falls Management notes once the resident had been identified stable, neurological signs for an unwitnessed fall where the resident is a poor historian will be documented on the neurological flow sheet for 72 hours. In addition, documentation is required for 72 hours to assess latent injuries.

Based on clinical record review observation, review of policy and interviews for 1 of 3 residents (Resident# 6) reviewed for pressure, the facility failed to ensure staff completed hand hygiene between donning and doffing gloves and failed to ensure staff utilized a cleansing solution (normal saline) that had not expired. The findings include: Resident #6 diagnosis included pressure ulcers and dementia. The care plan dated [DATE] indicated Resident #6 was at risk for alteration in skin integrity due to decreased mobility and had a history of pressure ulcers. Interventions included providing treatments as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was severely cognitive impairment and at risk for pressure ulcer noted with one unstageable pressure ulcer. On [DATE] from 11:50 AM through 12:20 PM an observation of a dressing change to Resident #6's right outer foot and interview with LPN #1 identified LPN #1collecting the items required to complete the dressing change prior to start of the observation. The bedside table was cleansed with an antibacterial wipe, clean paper towels were placed on the table with a small bottle of clear liquid, clean 4x4 dressings and a kerlix wrap. LPN #1 had a black marker and was noted writing on a small paper/tape and removed the top of the small bottle of clear liquid. LPN #1 applied a pair of non-sterile gloves. A nurse aide was in attendance to assist with turning and positioning Resident #6, once positioned, LPN #6 removed the dressing from Resident #6's right foot and placed it in the trash then removed the pair of gloves and donned a clean pair without the benefit of hand hygiene while reaching for a 4x4 dressing. Surveyor intervened and reminded LPN #1 of hand hygiene needed to be performed after removing (doffing) gloves. LPN #1 removed the gloves washed his/her hands and applied a clean pair of gloves and a 4x4 dressing and placed it on top of the solution bottle with one hand and with the other turned the bottle over slightly to pour liquid onto the dressing, cleansed the closed scabbed area of the outer right foot with the solution on the 4x4 then applied a kerlix wrap dressing. Resident #6 was repositioned by the nurse aide at the conclusion of the dressing change. LPN #1 then removed all the dressing items and paper towels and placed them in the trash except the small bottle of clear liquid which appeared at a distance to be over 3/4 full. LPN #1 removed the gloves and conducted hand hygiene the small bottle was brought to the cart outside the room. When asked to see the bottle it was noted to be a bottle of normal saline and to have a handwritten date in black marker on the cap indicating [DATE] (opened 13 days ago) and a manufactures' date of expiration stamped on the cap. LPN #1 indicated the marker date was when the bottle was opened and indicated the open bottle would be good to use until the manufacturers expiration date (2027). LPN#1 further indicated she/he was not sure if there was a facility policy related to how long an open bottle of normal saline could be used. On [DATE] at 12:50 PM an interview with the Infection Preventionist/wound nurse LPN #3 indicated hand hygiene should be completed before and after applying and removing gloves. LPN #3 indicated the saline bottles were good for 24 hours, but she/he would look to see if the manufacturer had a recommendation. LPN #3 indicated about a month ago the facility was no longer able to purchase normal saline in a spray bottle which had a longer shelf life and the small bottles of normal saline were purchased for use. LPN #3 was unaware of any training of staff regarding the transition from one form of saline to use of the new saline product. An interview and observation with Director of Nursing Services on [DATE] from 1:10 PM- 1:24 PM indicated the bottle of normal saline used during the earlier dressing change was discarded and the right foot dressing change was completed again under observation for proper hand hygiene and dressing change practice. The DNS indicated a new bottle of saline was used then discarded and pointed out on the bottle label in small writing with a notation for 1 time use. The DNS indicated no training had been provided regarding the use of a new product for wound care.

Based on review of the clinical record, facility documentation, facility policy, observation, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure the shower room door alarm was functioning to prevent a fall with injury. The findings include: Resident #1 had diagnoses that included dementia with behavioral disturbance, history of falls, vascular dementia, diabetes mellitus type 2, and hypertension. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition, was always incontinent of bowel and bladder, required moderate assistance with transfers, non-ambulatory, and independent with mobility using a manual wheelchair. The care plan dated [DATE] identified Resident #1 was at risk for falls because of the following: history of falls, weakness, impaired mobility, and impaired safety awareness with interventions that directed to encourage not to get up alone, encourage to wear nonskid footwear or nonskid socks, explain the routine to me, offer me education to use the call bell when I need assistance, place commonly used items within easy reach, and staff to ensure the overhead light is off after PM care. A physician's order dated [DATE] directed to transfer with the assist of one (1) and a rolling walker and ambulate on the unit with assist of one (1) and a rolling walker. A fall risk assessment dated [DATE] identified Resident #1 as a high risk for falls. A nurse's note dated [DATE] at 12:21 P.M. written by Registered Nurse (RN) #1 (7:00 AM- 3:00 PM supervisor), identified she was called to the unit and observed Resident #1 lying on h/her back on the floor in the shower room. RN #1 identified Resident #1 was bleeding from the occipital region on h/her head and noted to have a 2.0 centimeter laceration on the back of head. RN #1 identified APRN #2 was notified, and Resident #1 was transferred to the hospital. A nurse's note dated [DATE] at 12:50 P.M. written by RN #3 identified she was informed by the Licensed Practical Nurse (LPN) #1 that Resident #1 had fallen. RN #3 identified she observed Resident #1 laying on the floor in the shower room with a complaint about a head strike. RN #3 identified Resident #1 had an open area on the occipital area of h/her head with a small amount of blood coming from the area. RN #3 identified Resident #1 was sent to the emergency room for further evaluation. Review of the facility's accident and incident report dated [DATE] identified that on [DATE] at 11:10 A.M. Resident #1 was observed on the floor in the bathroom across from the recreation room. RN #1 assessed Resident #1 noting a 2.0-centimeter open area to the occipital area of h/her head orders were obtained to transfer Resident #1 to the emergency room. It was discovered that Resident #1 self-propelled out of the recreation room into the communal shower/bathroom. While in the emergency room a CT-scan of the chest revealed Resident #1 had acute fractures of the left 3rd, 4th, and 6th posterior ribs associated with a moderate size left hemo-pneumothorax. Resident #1 was admitted to the hospital upon return from the hospital Resident #1 will be evaluated by PT/OT for transfers, self-mobility, and wheelchair safety. Interview with Housekeeper #1 on [DATE] at 12:15 P.M. identified on [DATE] he observed Resident #1 lying on the floor in the shower room with h/her wheelchair pushed to the side. Housekeeper #1 identified the door to the shower room was open and the door alarm was not sounding. Housekeeper #1 identified he notified LPN #1 that Resident #1 was on the floor. Interview with LPN #1 on [DATE] at 3:00 P.M. identified on [DATE] Housekeeper #1 reported that Resident #1 was on the floor in the communal bath/shower room. LPN #1 identified on [DATE] when Resident #1 was found in the shower room lying on the floor, the door alarm on the shower room door was not alarming. LPN #1 identified the door alarm is on the shower door to prevent residents from going in the shower room unsupervised. LPN #1 identified the door alarm on the shower door doesn't always work because when the staff are done using the shower room a code needs to be entered to activate the door alarm and staff forget to turn it back on. Interview with RN #1 on [DATE] at 1:45 P.M. identified on [DATE] she was notified by LPN #1 that Resident #1 was found lying on the floor in the shower room. RN #1 identified upon arrival to the unit the door to the shower door was opened and door alarm was not alarming. RN #1 identified she observed Resident #1 on the floor in the shower room lying on h/her back and noted some bleeding coming from a small laceration on back of h/her head. RN #1 identified Advanced Practice Registered Nurse #2 was notified, an order was obtained to transfer Resident #1 to the emergency room. RN #1 identified when the shower room door alarm is activated it is very loud and can be heard throughout the unit. Interview with the DNS on [DATE] at 2:15 P.M. identified on [DATE] at approximately 10:30 A.M. Resident #1 was found by Housekeeper #1 lying on the floor in the shower room. The DNS identified he immediately went down to the unit, observed Resident #1 lying on the floor in the shower room with h/her wheelchair pushed to the side, and the shower room door alarm was not alarming. The DNS identified Resident #1 was transferred to the hospital and did not return. The DNS indicated the door alarm on the shower room door should have been alarming, however on on [DATE] the door alarm on the shower room door was not functioning because the battery had died and the DNS was unable to provide documentation to reflect the door alarm on the shower room door was monitored and maintained to ensure it proper functioning. Although requested, a facility shower room door alarm policy was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for activities of daily living, the facility failed to ensure the clinical record was complete and accurate to include documentation of personal care provided. The findings include: Resident #1 had diagnoses that included depressive disorder and Chronic obstructive pulmonary disease. Review of Resident #1's profile dated 8/1/24 directed the shower day as Tuesday on 3 P.M.-11 P.M. with special instructions to follow the master shower schedule. The care plan dated 8/2/24 identified Resident #1 needs help performing ADLs with interventions that directed to sign off care needs in POC (electronic charting system) and chartable tasks in POC are unchecked included on profile are checked. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was occasionally incontinent of bowel, always continent of bladder, was independent with bed mobility, required set up with transfers, required maximal assistance with showers, and moderate assistance with toileting, and toileting hygiene. Review of Resident #1's clinical record on 9/30/24 failed to identify any documentation to reflect any personal care provided from 8/1/24 to 8/15/24. Interview and clinical record review with the DNS on 9/30/24 at 12:30 P.M. was unable to provide documentation to reflect that personal care was provided to Resident #1. The DNS identified his expectations are that the nurse aide documents what personal care was provided on every shift into the resident's ADL flowsheets in the POC. The DNS identified Resident #1's ADL flowsheets should have been completed from 8/1/24 to 8/15/24. The DNS could not explain why the ADL flowsheets were not completed. Although requested, a facility documentation policy was not provided.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) sampled residents (Resident #2) who required a wheelchair for mobility within the facility, the facility failed to ensure when being assisted by staff the leg rests were present on the wheelchair to prevent the resident from falling out of the wheelchair. The findings include: Resident #2's diagnoses included cerebrovascular accident, unspecified dementia, hemiplegia on the right dominant side and muscle weakness. A physician's order dated 6/17/24 directed pop-over transfers with the assist of two (2) staff members, and the resident was non-ambulatory. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily life, was dependent with getting in and out of the bed and chair, had range of motion impairment of both upper extremities, was non-ambulatory and utilized a wheelchair for mobility. The Resident Care Plan dated 8/1/24 identified Resident #2 was a fall risk. Interventions directed to encourage the resident not to get up alone, encourage non-skid footwear and non-skid socks, educate on use of the call bell for assistance, and place commonly used items within reach. The nurse's note dated 8/7/24 at 3:37 PM identified at 2:30 PM Resident #2 was being pushed in the wheelchair during the recreation program, when Resident #2 fell forward out of the wheelchair and was noted with an open area to the right lateral scalp, actively bleeding. The note identified Resident #2 had intact neurological assessment, no changes in range of motion, no complaints of pain and no shortening/lengthening of extremities. The note indicated staff could not get the bleeding under control, the physician's assistant was notified, and a new order was obtained to send Resident #2 to the emergency department. The nurse's note dated 8/9/24 at 9:41 PM identified Resident #2 was readmitted to the facility at approximately 8:30 PM, sutures to the right temporal laceration were intake, and there were no changes in cognition and neuros were at baseline. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 8/28/24 at 12:11 PM identified on 8/7/24 it was reported to her Resident #2 had fallen out of the wheelchair. RN #1 identified Resident #2 was in the wheelchair without the benefit of having the leg rests on and Resident #2 put his/her foot down to the ground which caused Resident #2 to fall forward out of the wheelchair. RN #1 indicated Resident #2 should have had the leg rests on the wheelchair. Interview with the Director of Nursing (DON) on 8/28/24 at 12:17 PM identified Resident #2 sustained a fall forward from the wheelchair during transport. The DON identified the 7AM-3PM nurse aide, (Nurse Aide) #3, did not have the leg rests on the wheelchair at the time of the fall and the facility policy directs to always have the leg rests on the wheelchair. Interview with NA #3 on 8/28/24 at 12:29 PM identified she was pushing Resident #2 in the wheelchair without the benefit of leg rests on the wheelchair, and when she stopped the wheelchair, Resident #2 put his/her foot down on the floor and fell out of the wheelchair. NA #3 identified there should have been leg rests on the wheelchair while transporting Resident #2 but she forgot to put them on. Review of the facility policy titled Wheelchair, directed, in part, when wheelchair transporting any resident the leg rest must be used, and leg rests must always be used when transported by others.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of three sampled residents for accidents (Resident #1), the facility failed to ensure the physician was notified timely of a significant change in behavior. The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia with agitation, anxiety, and difficulty in walking. A quarterly MDS assessment 4/25/2024 identified Resident #1 had severe cognitive impairment, and independent to transfer and walk. A resident care plan (RCP) dated 6/9/2024 identified Resident #1 had a cognitive impairment due to dementia and history of involuntary weeping, wandering, refusing to participate in care and exit seeking behaviors with a wander guard placed. Interventions directed to offer snacks or coffee if demonstrating exit seeking behavior, redirect, observe for changes in mental status that are different from baseline and to refer to a psych provider as appropriate and for new exit seeking behavior have resident reviewed by psych. A psychiatric evaluation and consultation dated 6/6/2014 identified Trazadone (medication that treats depression) 50 mg TID was increased on 6/6/2024 due to increased agitation and an attempt to kick an NA. A psychiatric evaluation and consultation dated 6/14/2024 identified that Resident #1 was evaluated after a medication change. Resident #1 continued crying, though slightly improved. The plan was to continue to monitor Resident closely. No other concerns from nursing staff were reported and to continue the current treatment plan. A nursing note dated 6/15/2024 at 2:08 PM identified that Resident #1 was noted with increased behaviors; Resident #1 was observed standing in front of the unit attempting to hit a staff member. Staff attempted to redirect Resident #1 without success and a scheduled medication was administered. A call was placed to a family member who talked to Resident #1 with some success and Resident #1 was redirected to his/her room and offered coffee. At 12:35 PM, the unit nurse observed Resident #1 was standing on a chair in front of a partial opened secured window. Resident was placed on one to one (1:1) supervision and transferred to the hospital for evaluation. A nursing note dated 6/15/2024 at 10:38 PM identified that Resident #1 returned from the hospital at 5:20 PM and received scheduled medications. Resident #1 was observed wandering on unit but was easily redirected. A psychiatric evaluation dated 6/17/2024 identified that Resident #1 attempted to remove the screen from window over the weekend and had no recall of the event. Resident #1 was noted at baseline but due to given continued behaviors as well as some intermittent refusal of medications, Risperidone (medication that treats behavior) was increased. A psychiatric evaluation dated 6/19/2024 identified Resident #1 continued with confusion, but less agitation, and had no behaviors since last consult. The plan described to continue with redirection, may need to consider a higher level of care if continues with severe behaviors, and to continue to monitor symptoms. A psychiatric evaluation dated 6/28/2024 identified Resident #1 appeared more engaged and was noted to be stable by nursing staff with less behaviors and to continue treatment plan. A facility accident and investigation report dated 7/7/2024 at 2:30 PM identified an elopement event (missing resident). Resident #1 was not visualized on the unit during last rounds, a unit search was performed and the window in room [ROOM NUMBER] (not Resident #1's room) was open and the screen was removed. Dr. Hunt was initiated, and Resident #1 was found and returned to the unit without injury. Resident #1 was observed on the grass on an adjacent property (approximately 0.2 miles from the exit of window. The route took Resident #1 along a busy road with no sidewalks for 150 to 200 yards). Resident #1 was placed on 1:1 monitoring. A facility summary report dated 7/10/2024 identified that Resident #1's baseline behavior was that he/she walked freely throughout the unit with redirection if he/she wanders away from the common area. A nursing note dated 7/12/2024 at 5:19 AM identified Resident #1 was exit seeking and crying that she/he wanted to go home and went to the back door of the unit. A NA tried to stop Resident #1 and Resident #1 was kicking and punching the NA. The nurse tried to calm Resident #1 by offering a snack and drink. The note indicated it took a while for Resident #1 to calm down and eventually go to bed, and was noted sleeping. Record review failed to identify the physician/provider was notified of Resident #1's aggressive behaviors toward staff on 7/12/2024. Interview with APRN #1 (psychiatry) on 7/24/2024 at 11:50 AM identified her treatment plan was adjusted when Resident #1 became physically aggressive, as the baseline for Resident #1 was crying, wandering with elopement behaviors but was easily redirectable. She was unaware that Resident #1 had physical aggression when redirected on 7/12/2024. APRN #1 stated staff would either call her or leave a note in her follow up book on the unit if there was a change in condition, and she identified that she was not notified. APRN #1 stated she should have been notified and that she would have evaluated Resident #1 if she been informed to determine if there was a need to change the treatment plan at that time. APRN #1 further stated that on 7/20/2024 Resident #1 had become more agitated, combative with exit seeking behaviors and when the provider was notified, Resident #1 was transferred to the hospital for evaluation. Interview with Physician's Assistant (PA) #1 on 7/25/2024 at 9: 30AM identified that he was unaware that Resident #1 had demonstrated physical aggression on 7/12/2024 when being redirected for exit seeking behaviors. PA #1 stated if he was notified he would have then contacted APRN #1 to discuss any need to change the treatment plan at that time. Interview and review of facility documentation with LPN 2 on 7/25/2014 at 10:00 AM identified she was Resident #1's nurse on the 11 PM to 7 AM shift on 7/12/2024, and recalled Resident #1 became aggressive as the NA attempted to redirect him/her away from the back door of the unit. Resident #1 began to kick and punch the NA and it was very difficult to redirect the Resident. The usual coffee and snack eventually worked but it took some time. She could not recall if she notified the nursing supervisor or the physician/APRN. Interview with the DON on 7/25/2024 at 11:53 identified that if a Resident demonstrated increased behaviors with agitation staff should notify the supervisor who would notify the provider. He identified that Resident #1 had a history of physical aggression and that the staff were able to eventually calm Resident #1. The DON was unable to explain why the provider/APRN was not notified. Attempts to contact RN #2, 11 -7 supervisor, during survey were unsuccessful. The facility policy Condition, Significant change directed in part, that facility professional staff would communicate with the physician changes in condition to provide timely communication of resident status change that is essential to quality car management. The physician will be notified by the nurse in the event of a change in condition.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #2) reviewed for abuse, the facility failed to ensure care was provided in accordance with physician orders. The findings include: Resident #2 was admitted with diagnoses that included dementia and right sided hemiplegia (loss of movement on one side of the body). A quarterly MDS assessment dated [DATE] identified Resident #2 had severe cognitive impairment and was dependent for bed mobility. A resident care plan (RCP) dated 6/6/2024 identified Resident #2 required assistance with ALDs. Interventions directed to assist as indicated for positioning. A physician's order dated 6/25/2024 directed ADLs with assistance from two (2) staff. Transfer assistance of 2 staff via Hoyer lift. A facility reportable event form dated 7/11/2024 at 10:00 AM identified a hospice aide was providing care and noted multiple discolorations on Resident #2's body. A facility summary dated 7/11/2024 identified that Resident #2 was observed to have bruising on the right forehead, left hip, left arm, left hand, left elbow, left knee, left shoulder and right wrist and shearing was identified on the left hip. Resident #2 identified that he/she had fallen overnight and got back in bed. The summary identified NA #1 provided care during the 3 to 11 PM shift on 7/10/2024 (evening before the bruises were noted) with no bruising was noted. NA #2 (worked 11 PM to 7 AM ending on 7/11/2024) reported she observed Resident #2 on his/her left side in the bed with his/her legs hanging off the side of the bed, she was not aware of any falls during the shift, and no bruising was noted. NA #2 then attempted to re-center Resident #2 to the middle of the bed using a drawsheet. As she pulled the drawsheet, Resident #2's body turned more to the left and indicated although Resident #2's head was near the bedrail but Resident #2 did not hit his/her head. NA #2 then attempted to move Resident #2 towards the center of the bed, by holding his right wrist and moving him/her to the center of the bed. She completed this care by herself as she felt she did not require assistance at that time. Repeat demonstration of NA #2 providing care and discussion of care aligns with the areas of bruising. A nursing note dated 7/11/2024 at 10:26 AM identified she assessed Resident #2 due to multiple abrasions and ecchymosis (bruising) of the skin. On assessment an abraded area to left hand, shoulder and hip as well as small ecchymosis to right side of head. Resident #2 had complaints of pain in hip and shoulder and x-rays were ordered of left hip, shoulder, elbow and hand. A nursing progress note dated 7/11/2024 at 9:16 PM identified x rays were negative and no new orders. Interview with NA #2 on 7/25/2024 at 1:11 PM identified around 12:30 AM she observed Resident #2 with his/her legs hanging off the lower part of the bed. She raised the bed and put Resident #2's legs back on the bed when Resident #2 again kicked them off the bed. NA #2 again placed Resident #2's legs back onto the bed. NA #2 stated she then used the drawsheet to pull Resident #2 into the center of the bed and using the draw sheet she again pulled Resident #2 towards her. NA #2 stated she may have grabbed Resident #2's right arm to as she adjusted his/her position. Resident #2 did not resist care or report any discomfort at the time. NA #2 stated she did not check the care card prior to providing care and was not aware at the time that Resident #2 needed 2 staff to provide care, and stated after 7/11/2024, she was re-educated to always check the care card prior to providing care. Interview and review of the 7/11/2024 investigation documents with the DON on 7/25/2024 at 12:40 PM identified NA #2 repositioned Resident #2 alone. The DON stated NA #2 re-demonstrated the way she repositioned Resident #2 and the injuries were consistent with the care NA #2 had provided. The DON stated NA #2 should have reviewed the level of care Resident #2 required, and should not have provided the care without help. Although requested, the facility was unable to provide a policy on turning and positioning.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three sampled residents for accidents (Resident #1), the facility failed to ensure supervision to prevent the resident from exiting the facility without staff knowledge, and failed to notify local law enforcement timely when a resident was identified missing, and failed to complete a quarterly elopement risk assessment timely in accordance with facility policy. The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia with agitation, anxiety, and difficulty in walking. A quarterly MDS assessment 4/25/2024 identified Resident #1 had severe cognitive impairment, and independent to transfer and walk. A resident care plan (RCP) dated 6/9/2024 identified Resident #1 had a cognitive impairment due to dementia and history of involuntary weeping, wandering, refusing to participate in care and exit seeking behaviors with a wander guard placed. Interventions directed to offer snacks or coffee if demonstrating exit seeking behavior, redirect, observe for changes in mental status that are different from baseline and to refer to a psych provider as appropriate and for new exit seeking behavior have resident reviewed by psych. Record review identified Resident #1 resided on the secure dementia unit. A nursing note dated 6/15/2024 at 2:08 PM identified that Resident #1 was noted with increased behaviors; Resident #1 was observed standing in front of the unit attempting to hit a staff member. Staff attempted to redirect Resident #1 without success and a scheduled medication was administered. A call was placed to a family member who talked to Resident #1 with some success and Resident #1 was redirected to his/her room and offered coffee. At 12:35 PM, the unit nurse observed Resident #1 was standing on a chair in front of a partial opened secured window. Resident was placed on one to one (1:1) supervision and transferred to the hospital for evaluation. A nursing note dated 6/15/2024 at 10:38 PM identified that Resident #1 returned from the hospital at 5:20 PM and received scheduled medications. Resident #1 was observed wandering on unit but was easily redirected. A review of facility documentation dated 6/16/2024 identified Resident #1 was reported to have opened the window in room [ROOM NUMBER]. All windows on the secured dementia unit were evaluated by maintenance and determined to open approximately six (6) to eight (8) inches with a screw securely in place to prevent window from being opened further. All screens were noted to be intact. A psychiatric evaluation dated 6/17/2024 identified that Resident #1 attempted to remove the screen from window over the weekend and had no recall of the event. Resident #1 was noted at baseline but due to given continued behaviors as well as some intermittent refusal of medications, Risperidone (medication that treats behavior) was increased. A psychiatric evaluation dated 6/17/2024 identified that Resident #1 attempted to remove the screen from window over the weekend. Resident #1 had no recall of the event. Resident #1 was noted at baseline but due to given continued behaviors as well as some intermittent refusal of medications, Risperidone increased. A psychiatric evaluation dated 6/19/2024 identified Resident #1 continued with confusion, but less agitation, and had no behaviors since last consult. The plan described to continue with redirection, may need to consider a higher level of care if continues with severe behaviors, and to continue to monitor symptoms. A facility accident and investigation report dated 7/7/2024 at 2:30 PM identified an elopement event (missing resident). Resident #1 was not visualized on the unit during last rounds, a unit search was performed and the window in room [ROOM NUMBER] (not Resident #1's room) was open and the screen was removed. Dr. Hunt was initiated, and Resident #1 was found and returned to the unit without injury. Resident #1 was observed on the grass on an adjacent property (approximately 0.2 miles from the exit of window. The route took Resident #1 along a busy road with no sidewalks for 150 to 200 yards). Resident #1 was placed on 1:1 monitoring. A nursing progress note dated 7/7/2024 at 5:45 PM identified that per the charge nurse, Resident #1 was not observed for 15 minutes prior to her being informed, and the DON, Administrator and family were notified. Assessment upon return to the facility was: vital signs Temperature 98.4, Heart Rate 81, Blood pressure 100/50, Respiratory Rate 18 with oxygen saturation at 93 percent. A nursing note dated 7/8/2024 at 3:36 PM identified that the plan was to have Resident #1 remain on every 15-minute checks times 24 hours, then 30-minute checks times 24 hours then every 4-hour checks times 24 hours and then every shift checks times 48 hours. A facility summary report dated 7/10/2024 identified that Resident #1's baseline behavior was that he/she walked freely throughout the unit with redirection if he/she wanders away from the common area. A facility summary report dated 7/10/2024 identified that Resident #1's baseline behavior was that he/she walked freely throughout the unit with redirection if he/she wanders away from the common area. At 1:50 PM, staff confirmed they observed Resident #1 walking in the hallway on the unit. At approximately 2:00 PM, staff were not able to visualize Resident #1's whereabouts, a unit search was initiated, and it was noted that in another resident's room (409), there was a window open past the secure stopper and the screen was not in place. The window was 38 inches from the ground. At 2:07 PM (7 minutes after identified missing), Resident was observed on the property adjacent to the facility. An RN assessment was completed, no injury was identified, and Resident #1 denied any pain. After clearance from psych, Resident #1 was placed on every 15-minute check. All windows on the unit were check and all other windows had the safety stop in place and intact. Additional reinforcement was completed with 2 screws and an additional stopper device was placed to prevent the bending of any screws as this was what was determined to have happened for Resident #1 to force the window open. Interview with NA #1 on 7/24/2024 at 11:15 AM identified that she was assigned to care for Resident #1 on 7/7/2024. During her last rounds, at approximately 2:00 PM she noticed that Resident #1 was no longer by the nurse's station or observed walking in the hallway. She immediately went to his/her room as a staff member told her they had redirected the Resident to his/her room. She looked in the room and Resident #1 was not there, so she began to check the other rooms. In room [ROOM NUMBER], she observed that the window was open, no screen and that a wheelchair had been placed by the window. She immediately told the charge nurse, and Dr. Hunt was called. NA #1 ran outside with another NA and proceeded to the left of the building and began to walk along the road. As she approached the building on the corner of the road, she could see Resident #1 lying on the ground on the other side of the building on a hill at the back of the side parking lot of the building. Resident #1 had taken all his/her clothes off except for pants and when she got to Resident #1, he/she stated he/she was hot. Another NA had driven her car over and they placed Resident #1 into the car and drove him back to the facility. Interview and observations of Resident #1's route to the building adjacent to the facility with the DON on 7/24/2024 at 11:30 AM identified Resident #1 removed the screen from the window of room [ROOM NUMBER]. From there, a sidewalk runs along the side of the building that ends on the road in front of the facility. The road in front of the facility was a three-lane road, and included a three-way stop light intersection. A wooded area was located between the facility and the adjacent building next door with no visible paths through the wooded area and the adjacent building. The DON identified when he completed the investigation, he could see the adjacent building through the trees, and stated the ground was uneven with no path noted. Resident #1 had no scratches, cuts or bruises or any debris on his/her clothing when assessed on 7/7/2024 and was unable to identify if Resident #1 walked along the road or through the woods. The DON stated the last time Resident #1 was reported seen on the unit was at 1:45 PM, was discovered missing at 2: 00 PM and was then found at 2:07 PM, approximately 22 minutes after Resident #1 was last seen on the unit. A review of weather temperatures recorded on July 7, 2024 identified that the outside temperature was recorded at 93 degrees Fahrenheit with a dew point of 70 percent (a dew point of 70 is considered oppressive and very uncomfortable). The facility Elopement Policy directed in part, that the facility strived to promote safety for all residents at risk for elopement. Elopement is defined as the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and who may enter into harm's way. a. Interview with the DON on 7/25/2024 at 11 AM identified that he was notified by the nursing supervisor (RN #1) at approximately 2:00 PM that Resident #1 was not located on the unit, and he directed RN #1 to initiate a Dr. Hunt and start the search. The DON stated he was notified at 2:07 PM that Resident #1 was located off property grounds behind an adjacent building. The facility policy Elopement directed in part, that the police should be notified as soon as the resident is not located with the facility or on immediate grounds. b. A quarterly elopement assessment dated [DATE] identified Resident #1 was at risk for elopement. An elopement assessment dated [DATE] identified Resident #1 was completed when Resident #1 forced open a window on the secured dementia unit and left property unattended. Resident #1's medical record lacked a completed quarterly elopement assessment due April 2024. Interview with the DON 7/25/2024 at 11 AM identified that an assessment for elopement should be completed quarterly. The DON stated an assessment should have been completed three (3) months after the 1/23/2024 assessment and he did not know why one was not completed when due. The facility policy Elopement directed in part, that a licensed nurse will conduct an Elopement risk screen on admission, annually, quarterly and upon a change in condition.

Based on clinical record review, facility documentation, and interviews, The facility failed to ensure that (1) of three (3) residents reviewed for abuse, (Resident #11), was free from sexual abuse, and for one (1) of three (3) residents reviewed for incontinent care and turning and repositioning, (Resident # 4), the facility failed to ensure that the resident was free from neglect. The findings included: 1. Resident #10 had a diagnosis of dementia. An annual Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severely impaired cognition, had no behaviors or changes in mood, required substantial assistance with Activities of Daily Living (ADL's), and was independent with ambulation. A care plan dated 4/7/24 identified that the resident had cognitive loss related to a diagnosis of dementia with interventions that included psychiatric evaluations as indicated, administer medications as ordered, and to provide re-direction. A nurse's note dated 5/6/24 at 4:04 PM identified that the resident was in the roommates bed undressed from the waist down touching Resident #11's genital area and h/her own genital area at the same time. The residents were immediately separated and Resident #10 was placed on 1:1 supervision. 2. Resident #11 had a diagnosis of dementia. A significant change MDS dated [DATE] identified that the resident has severely impaired cognition, and was dependent on staff for ADL's. A care plan dated 4/7/24 identified that the resident had cognitive loss due to dementia with interventions that directed to administer medications as ordered and refer to psychiatric services as needed. A nursing note dated 5/6/24 at 2:35 PM identified that the resident's roommate was noted to be in h/er bed touching Resident #11's genital area, the resident had no recollection of the event, an exam was performed and no abnormalities were assessed. The resident was seen by social services and had a room change. a) A Reportable Event dated 5/6/24 at 9:00 AM identified that Resident #10 was found in Resident #11's bed ( the 2 residents are roommates). Resident #10 had h/her hands on Resident #11's genital area. Interview with Licensed Practical Nurse (LPN) #5 on 5/6/24 at 10:50 AM identified that she had entered Resident #10 and Resident #11's room to do wound care on Resident #11, the door was open, and the curtain was drawn between the two beds. Resident #10 was lying behind Resident #11 in bed undressed from the waist down, and Resident #11 still had an adult brief on, however, it was undone and Resident #10 had h/her hands on Resident #11's genital area, while h/her hand was on h/her own genitals. The resident's were immediately separated and Resident #10 was placed on 1:1 supervision, and Resident was given a room change. Interview with RN #1 on 5/6/24 at 2:01 PM identified that by the time she was called to the room the residents were already separated, she completed a physical assessment on both resident and no injury or abnormalities were identified. The physician and families were updated and Resident #10 remained on 1:1 until a psychiatric evaluation could be completed. Interview with the Psychiatric Advanced Practical Registered Nurse (APRN) on 5/6/24 at 2:30 PM identified that Resident #10 did not have any history of sexually inappropriate behaviors and it was her thought that it was due to a progression in dementia. The APRN identified that she had adjusted Resident #10's trazdone the week prior, so she did not do any medication adjustments on Resident #10. Resident #10 was assessed not to be a danger to self or others, so one to one supervision was discontinued and every 15 minute checks were started. Additionally, neither Resident #10 or Resident #11 had any recollection of the event upon assessment. Review of the abuse policy identified that each resident has the right to be free from abuse. 3. Resident # 4 had a diagnosis of dementia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment, was dependent on staff for all ADL's, was always incontinent of bowel and bladder, and was at risk for developing pressure ulcers. A care plan dated 4/7/24 identified that the resident was at risk for skin breakdown related an inability to respond to pressure related discomfort, impaired mobility and bowel and bladder incontinence with interventions that included assistance with position changes every 2 hours, and incontinent care per facility protocol. Constant observation on 5/6/24 from 9:45 AM to 1:45 PM identified the following: a. From 9:45 AM until 10:00 AM the resident was seated across from the nurses station in a wheelchair with h/her body position leaning to the left side. b. At 10:00 AM the resident was taken into the recreation room for an activity. c. At 11:02 AM the resident was taken from the lounge by a visitor to the lounge at the end of the hallway, and brought back to the lounge by the nurse's station at 11:10 AM. d. from 11:10 AM until 11:45 AM the resident was seated in the lounge with h/her body positioned leaning to the left side. e. At 11:45 AM the resident was taken from the lounge and brought down to the lounge at the end of the hallway for lunch, she was seated to the left of the main table in her wheelchair. f. At 12:30 PM the resident was fed lunch, after lunch the resident remained in the lounge for an activity until 1:45, the residents body position was still leaning to the left. At 1:45 PM the surveyor informed LPN #1 that the resident had not received any incontinent care or repositioning from 9:45 AM until 1:45 PM (a total of 4 hours). Subsequent to surveyor inquiry the resident was taken back to h/her room for care. Surveyor entered the room at 2:00PM while care was already in progress, the resident had already been hoyered into bed and NA#1 stated that she had not yet performed any incontinent care. Observation identified that the resident had not been incontinent and the brief that the resident was wearing was dry. A skin check of the resident identified a 5 centimeter (cm) by 1 cm blanchable area of redness on the residents left hip. Observation on 5/7/24 at 10:00 AM with LPN #1 identified that the balanceable area of redness to the left hip had resolved. Interview with Nurse Aide #1 on 5/6/24 at 2:00 PM identified that she was the NA assigned to Resident # 4, and Resident #4's hospice NA had done morning care on the resident, however, she wasn't sure what time care was given. NA#1 identified that she had not checked the resident for incontinence or repositioned the resident until after surveyor inquiry at 1:45 PM because she had 13 residents on her assignment, and she had been busy all morning with care for the other residents. Interview with LPN #1 on 5/7/24 at 2:10 PM identified that she was Resident #4's nurse and she had a total of 26 residents on her floor with 2 NA. She further identified that NA #1 did not notify her that she could not provide care for Resident #4, if she had been notified she would have called the supervisor. Interview with the nursing supervisor for the 7:00 AM to 3:00 PM shift (RN)# on 5/6/24 at 2:45 PM identified that she was not aware that NA #1 was having difficulty with h/her assignment, if she was aware she would have made adjustments to the assignments. Interview with the Director of Nurses on 5/6/24 at 2:50 PM identified that Resident #4 should have been checked for incontinence, and changed if soiled and repositioned every 2 hours in accordance with facility policy.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #1 and #3) reviewed for pressure ulcers, the facility failed to create and implement a care plan for newly identified wounds. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included type II diabetes and dementia. The care plan dated 1/5/24 identified Resident #1 was at risk for skin breakdown with interventions that included assisting Resident #1 with position changes approximately every 2 hours and as indicated, pressure reducing relieving devices, and to offer to offload Resident #1's heels when in bed. The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at high risk for developing pressure ulcers. A nursing note dated 2/24/24 at 6:50 PM identified Resident #1 was noted with an opening to the coccyx measuring 1 centimeter (cm) x 1 cm. The site was superficial, clean and pink with no signs of infection. The APRN was updated with new orders in place for triad mixed with Aquaphor for 14 days. Review of Resident #1's medical record failed to identify Resident #1's care plan was updated to include Resident #1's coccyx wound and appropriate interventions. A nursing note dated 3/16/24 at 4:20 PM identified the on call APRN was notified of Resident #1's change in coccyx area. The plan was to monitor and place in wound care book for re-evaluation on 3/18/24. Resident #1's family member was notified and wanted Resident #1 to be sent to the hospital. The APRN was updated and Resident #1's family member went to the hospital with Resident #1. A nurse practitioner note dated 3/19/24 at 10:02 AM identified review of Resident #1's hospitalization was for Resident #1's coccyx wound. Resident #1's coccyx wound was not infected and no interventions were done beyond basic wound care. Resident #1 was seen by the wound care nurse who recommended to cleanse the wound with soap and water, apply skin barrier cream to wound and cover cream with a full sheet of xeroform twice a day and as needed. Review of Resident #1's medical record failed to identify Resident #1's care plan was updated to include Resident #1's progressing coccyx wound with interventions. 2. Resident #3 was admitted to the facility on with diagnoses that included neuromyelitis Optica (autoimmune nerve disease), neurofibromatosis (tumors grow in the nervous system) and an intellectual disability. The care plan dated 2/28/24 identified Resident #3 was at risk for skin breakdown with interventions that included assisting Resident #3 with position changes approximately every 2 hours and as indicated, offer to take Resident #3 to the bathroom every 2 hours and as needed, when incontinent provide care per protocol, pressure reducing relieving devices, and to offer to offload Resident #3's heels when in bed. The admission MDS dated [DATE] identified Resident #3 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at risk for developing pressure ulcers. A nursing note dated 3/18/24 at 7:00 AM identified she was informed by the unit nurse that Resident #3 was noted with a red area to the mid coccyx and buttocks. A linear 3 cm area of denuded skin at the right buttocks was assessed. The area was cleansed with normal saline and triad was applied. A nursing note dated 3/18/24 at 12:05 PM identified Resident #3 was seen by the wound team secondary to bilateral buttock diffused moisture associated skin damage (MASD) with no drainage noted. The site was cleansed with normal saline followed by triad cream. Review of Resident #3's medical record failed to identify Resident #1's care plan was updated to include Resident #3's progressing coccyx wound and interventions. Subsequent to surveyor inquiry, Resident #3's care plan was updated on 5/7/24 to include the problem that Resident #3 had a stage four pressure ulcer on his/her coccyx with interventions that included to notify the supervisor/physician of any changes in the wound, supplements as ordered, encourage completing of all foods and fluids, treatments as ordered by the wound physician and weekly wound measurements. Interview with the ICN on 5/7/24 at 2:57 PM identified she gives a list of wounds to the MDS coordinator weekly and the MDS coordinator would create or change the resident's care plan. She further identified for a resident with a pressure ulcer/injury, they should have a care plan in place. Interview with the MDS coordinator on 5/7/24 at 3:15 PM identified she was the MDS coordinator for Resident #1 and Resident #3. She identified she gets a wound list weekly and adds them to the resident's care plans. She identified she must have missed imputing Resident #1's wound to the care plan. She further identified she thought she added Resident #3's wound interventions to the care plan but checked Resident #3's care plan and they were not there. Review of the comprehensive care plan policy identified care plans are oriented toward preventing avoidable decline in clinical and functional levels, maintain a specific level of functioning and reflect resident preferences and rights. It identified the interdisciplinary team develops a comprehensive care plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs identified in the RAI and IDT. It further identified the care plan is evaluated and revised as needed, but at least quarterly.

Based on review of the clinical record, facility policy, facility documentation, and interviews for one of three residents (Resident #9) reviewed for falls, the facility failed to follow a care plan. The findings included: Resident #9 diagnoses included Alzheimer's disease, muscle weakness, and difficulty walking. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 as severely cognitively impaired, required maximal assistance with toileting, dressing, and personal hygiene, and utilized both a walker and wheelchair for mobility. Review of the Resident Care Plan dated 2/18/24 identified a risk for falls due to a history of falls, weakness, impaired mobility, and impaired safety awareness with interventions that directed to encourage non-skid footwear or non-skid socks. Review of a Reportable Event form dated 3/11/24 identified Resident #9 was observed on the floor next to the nurse's station which resulted in a hematoma and laceration to the back of his/her head. Review of the fall observation dated 3/11/24 identified Resident #9 was wearing regular socks (not non-skid) and that Resident #9 was forgetful and would ambulate independently. Interview with the Infection Control Nurse on 5/6/24 at 3:05 PM identified Resident #9 should have been wearing non-skid socks as he/she was care planned to wear non-skid socks. The Infection Control Nurse further identified it was the certified nurse's aide's and nurse's responsibility to ensure the correct footwear was applied. Interview with NA #5 on 5/7/24 at 11:20 AM (who was assigned to Resident #9's care on 5/7/24) identified it was the her responsibility to follow the care plan directive and apply non-skid socks to the resident. Review of the Comprehensive Care Plan policy indicated the Interdisciplinary Team develops a Comprehensive Care Plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs.

Based on clinical record review, facility documentation, and interviews for one (1) of three (3) residents, (Resident #5), who was dependent for incontinent care and repositioning, the facility failed to ensure that the resident was given care in a timely manner. The findings included: Resident #5 had a diagnosis of dementia. A care plan dated 4/5/24 identified that the resident was at risk for pressure ulcers related to inability to respond to pressure related discomfort, impaired mobility, and bowel and bladder incontinence with interventions that included position changes every two (2) hours and incontinent care per facility protocol. An admission Minimum Data Set (MDS) dated [DATE] identified that the resident had severely impaired cognition, required total care with activities of daily living (including bed mobility), was always incontinent of bowel and bladder, had moisture associated dermatitis (skin inflammation caused by prolonged exposure to moisture), and was at risk for pressure ulcers. Observation on 5/6/24 at 11:45 AM identified that a family member had approached the nurse's station with concerns about Resident #5 on whether or not the resident had received morning care as the resident was still in bed in a johnny. Interview with Nurse Aide (NA) #6 on 5/6/24 at 11:50 AM identified that he/she had Resident #5 on her assignment and had provided incontinent care and repositioning at approximately 8:30 AM that morning. NA #6 further identified that she had a very busy morning with an assignment of 15 residents and only one other NA on the floor. The reason Resident #5 was still in bed at 11:45 AM and had not received incontinent care and positioning since 8:30 (3 hours and 15 minutes) was that the resident required assistance of 2 people and she had not had an opportunity to get back to the resident with a second NA #6 also had 15 residents on her assignment. Interview with LPN # 6 identified that she was Resident #5's nurse for the 7:00 AM to 3:00 PM shift and the census on the unit was 30, and had 2 NA. She was unaware that the NA's were having difficulties completing their assignments. Interview with the nursing supervisor on 5/6/24 at 1:00 PM identified that if she had been notified that the NA's were having difficulty completing the assignment, she would have made adjustments to the staffing. Interview with the Director of Nurses on 5/6/24 at 2:00 PM identified that if the NA were having difficulty with their assignment they should have let the charge nurse/supervisor know. Additionally the resident should have been turned and repositioned and given incontinent care every 2 hours. x

Based on clinical record review, facility documentation, and interviews for one (1) of three (3) residents reviewed for nutrition, (Resident #6), the facility failed to ensure that a resident who had a diagnosis of dysphagia was properly positioned during mealtime. The findings included: Resident #6 had a diagnosis of dysphagia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had intact cognition, and was dependent on staff for activities of daily living including eating. A care plan dated 4/6/24 identified that the resident was at risk for choking/aspiration with swallowing due to a diagnosis of dysphagia with interventions that directed to provide the diet as ordered and elevate the head of the bed 90 degrees during mealtime and to observe for signs and symptoms of aspiration. A physician's order dated 4/1/124 directed the resident to receive a puree diet with thin liquids. Observation on 5/6/24 at 9:10 AM identified Nurse Aide (NA) # 2 feeding Resident #6 in bed, the resident has a neck pillow on, however, the bed was flat, and the head of the bed was not elevated. Interview with NA #2 at the time of the observation identified that she had fed the resident the pureed eggs and some of the oatmeal, however, she didn't think to elevate the head of the bed. Interview and observation with LPN #7 of Resident #6's positioning during mealtime on 5/6/24 at 9:12 AM identified that Resident #6 was on aspiration precautions and the head of the bed was not elevated as it should have been during mealtime to 90 degrees. Interview with the speech therapist on 5/6/24 at 12:21 PM identified that Resident #6 has dysphagia and is on aspiration precautions and refuses to get out of bed for meals. Resident #6 has cervical spine issues and if the head of h/her bed is elevated too much it causes pain, however, the head of the bed should never be flat and for Resident #6 the head of the bed should have been at least 75 to 80 degrees elevated to prevent the potential for aspiration. Review of the aspiration precaution policy identified that the aspiration precaution policy will be utilized to prevent the aspiration of food into a resident's lungs and aspiration precautions will be individualized for each resident.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1) reviewed for pressure ulcers, the facility failed to assess and document changes in the resident's skin. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included type II diabetes and dementia. The nursing admissions assessment dated [DATE] at 4:00 PM identified Resident #1 had no pressure ulcers and was at risk for developing pressure ulcers/injuries. The physician's orders dated 1/4/24 directed an assist of two staff for activities of daily living (ADL's), an assist of two staff with a Hoyer lift for transfers and triad topical for rash. The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at high risk for developing pressure ulcers. The care plan dated 1/5/24 identified Resident #1 was at risk for skin breakdown with interventions that included assisting Resident #1 with position changes approximately every 2 hours and as indicated, pressure reducing relieving devices, and to offer to offload Resident #1's heels when in bed. A physician's order dated 1/11/24 directed Aquaphor to peri-area every shift with incontinence care per family. a. A nurse's note dated 2/18/24 at 7:40 PM identified Resident #1's family member had complaints of Resident #1's buttocks, stating Resident #1's wound had returned because staff was not applying Aquaphor (a skin protectant). LPN #6 assessed Resident #1's buttocks, applied Aquaphor, and notified the supervisor. A nursing note dated 2/24/24 at 6:50 PM identified Resident #1 was noted with an opening to the coccyx measuring 1 centimeter (cm) x 1 cm. The site was superficial, clean and pink with no signs of infection. The APRN was updated with new orders in place for triad mixed with Aquaphor for 14 days. The wound notification form was completed. Wound care documentation dated 2/28/24 at 9:55 PM identified Resident #1 was seen by the wound care team secondary to Moisture Associated Dermatitis (MASD)on Resident #1's coccyx measuring 0.5 cm x 0.5 cm x 0.1 cm, 100% granulation tissue and scant amount of drainage noted, a New order for triad cream every shift was obtained. Wound care documentation dated 3/4/24 at 11:22 AM identified Resident #1's coccyx wound was stable, measuring 0.5 cm x 0.5 cm, 100% non-granulation tissue, no drainage and to continue the current treatment. Wound care documentation dated 3/12/24 at 9:36 PM identified Resident #1's coccyx wound was improving, measuring 0.3 cm x 0.3 cm x 0.1 cm, no drainage noted and to continue the current treatment. A RN nursing note dated 3/16/24 at 4:20 PM identified the on call APRN was notified of Resident #1's change in coccyx area. The plan was to monitor and place in wound care book for re-evaluation on 3/18/24. Resident #1's family member was notified and wanted Resident #1 to be sent to the hospital. The APRN was updated and Resident #1's family member went to the hospital with Resident #1. A nurse practioner note dated 3/19/24 at 10:02 AM identified review of Resident #1's hospitalization was for Resident #1's coccyx wound. Resident #1's coccyx wound was not infected and no interventions were done beyond basic wound care. Resident #1 was seen by the wound care nurse who recommended to cleanse the wound with soap and water, apply skin barrier cream to wound and cover cream with a full sheet of xeroform twice a day and as needed. A nurse's note written by LPN #7 dated 3/24/24 at 2:15 PM identified Resident #1's treatment to the sacral area was done as ordered and a dressing applied, a foul odor was noted with no drainage. A nurse practioner note dated 3/25/24 at 11:31 AM identified per wound care, Resident #1's sacral wound was worsening, however the wound was not assessed. Wound care documentation dated 3/25/23 at 12:23 PM identified Resident #1's coccyx wound, now unstageable, was declining, measuring 4 cm x 3 cm, unknown depth a new order to clean with normal saline followed by santyl followed by calcium alginate followed by boarded foam. A nursing note dated 3/25/24 at 12:23 PM identified Resident #1 was seen today by the wound care team secondary to MASD on Resident #1's coccyx which was now an unstageable ulcer measuring 4 cm x 3 cm with the depth unknown. a small amount of drainage noted with 75% slough and 25% epi tissue. A new order to clean the area with normal saline, followed by santyl and calcium alginate followed by bordered foam. Interview with RN #2 on 5/7/24 at 2:13 PM identified she was not notified of the odor from Resident #1's wound by LPN #7 on 3/24/24. She identified if she were notified, she would have assessed the wound, including measuring it and checking for drainage and then would notify the physician. Although multiple attempts were made, an interview with LPN #7 was not obtained. b. A nurse's note dated 4/3/24 at 3:09 PM identified during Resident #1's dressing change and repositioning, LPN #3 observed an open area to the left of Resident #1's coccyx ulcer measuring 1.2 cm x 1.2 cm and the Physician's assistant was updated with the new order to apply triad cream every shift. Interview with LPN #3 on 5/7/24 at 10:30 AM identified she notified RN #1 (supervisor on 4/3/24) of the newly identified open area to the left of Resident #1's coccyx wound. Interview with RN #1 on 5/7/24 at 11:33 AM identified she had assessed Resident #1's newly identified wound notified by LPN #3, however, she failed to document a progress note and probably forgot. She further identified a nursing note should be documented for any changes in residents' skin. c. A nurse's note written by LPN #1 dated 4/6/24 at 10:22 PM identified triad cream was applied to the left coccyx ulcer and Aquaphor to his/her peri area as ordered. Resident #1's dressing was soiled and changed, and a smelly odor was noted prior to the dressing change and the supervisor was made aware. A physician's assistant note dated 4/9/24 at 12:12 PM identified he attempted to discuss Resident #1's poor oral intake and wound healing with his/her conservator. It identified there were no reports of wound infection by the wound care team and that Resident #1's conservator persisted on having Resident #1 evaluated in the hospital despite it not changing the management of Resident #1's wound. A physician's order dated 4/9/24 directed to transfer Resident #1 to the emergency department for an evaluation of Resident #1's non-healing coccyx wound per Resident #1's emergency contact. Although multiple attempts were made, an interview with LPN #1 was not obtained. Interview with RN #2 on 5/7/24 at 2:13 PM identified she was not notified of the odor from Resident #1's wound by LPN #1 on 4/6/24. She identified if she were notified, she would have assessed the wound, including measuring it and checking for drainage and then would notify the physician. Interview with the ICN nurse on 5/6/24 at 1:30 PM identified herself and wound nurse are both LPN's and report to the DNS of any changes in the resident's wounds status. Interview with the DNS on 5/7/24 at 3:00 PM identified for any changes in condition such as changes in a resident's wound status, the LPN should alert the RN and the RN should complete and document an assessment and interventions, if any. Interview with the facility Nurse Practitioner on 5/8/24 at 11:58 AM identified the facility practitioners/physicians should be notified of a change in a resident's wound, such as a new odor. Review of the significant change policy identified that the physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition and that the notification should be documented in the clinical record.

Based on clinical record review, facility documentation, and interviews for two (2) of fifteen (15) residents reviewed for activities of daily living, (Resident #4 and Resident #5), the facility failed to ensure adequate staffing to meet the needs of the residents. The findings include: Review of the nursing schedule from 7:00 AM to 9:00 PM for 5/6/24 identified that the facility met the requirements of the state agency for staffing , however, for the Evergreen unit and the [NAME] unit, staffing was not sufficient to meet the needs of the residents. The Evergreen unit had a census of 26 residents and had 2 Nurse Aides (13 residents each) and the [NAME] unit had 30 residents and 2 NA (15 residents each) 1. Resident # 4 had a diagnosis of dementia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment, was dependent on staff for all ADL's, was always incontinent of bowel and bladder, and was at risk for developing pressure ulcers. A care plan dated 4/7/24 identified that the resident was at risk for skin breakdown related an inability to respond to pressure related discomfort, impaired mobility and bowel and bladder incontinence with interventions that included assistance with position changes every 2 hours, and incontinent care per facility protocol. Constant observation on 5/6/24 from 9:45 AM to 1:45 PM identified the following: a. From 9:45 AM until 10:00 AM the resident was seated across from the nurses station in a wheelchair with h/her body position leaning to the left side. b. At 10:00 AM the resident was taken into the recreation room for an activity. c. At 11:02 AM the resident was taken from the lounge by a visitor to the lounge at the end of the hallway, and brought back to the lounge at 11:10 AM. d. from 11:10 AM until 11:45 AM the resident was seated in the lounge with h/her body position leaning to the left side. e. At 11:45 AM the resident was taken from the lounge and brought down to the lounge at the end of the hallway for lunch, she was seated to the left of the main table in her wheelchair. f. At 12:30 PM the resident was fed lunch, after lunch the resident remained in the lounge for an activity until 1:45, the residents body position was still leaning to the left. At 1:45 PM the surveyor informed LPN #1 that the resident had not received any incontinent care or repositioning from 9:45 AM until 1:45 PM (a total of 4 hours). Subsequent to surveyor inquiry the resident was taken back to h/her room for care. Surveyor entered the room while care was already in progress, the resident had already been hoyered into bed and NA#1 stated that she had not yet performed any incontinent care. Observation identified that the resident had not been incontinent and the brief that the resident was wearing was dry. A skin check of the resident identified a 5 centimeter (cm) by 1 cm blanchable area of redness on the residents left hip. Observation on 5/7/24 at 10:00 AM with LPN #1 identified that the blanchable area of redness had resolved. Interview with Nurse Aide #1 on 5/6/24 at 2:00 PM identified that she was the NA assigned to Resident # 4, and Resident #4's hospice NA had done morning care on the resident, however, she was not sure what time care was given. NA#1 identified that she had not checked the resident for incontinence or repositioned the resident until after surveyor inquiry because she had 13 residents on her assignment, and she had been busy all morning with care for the other residents. Interview with LPN #1 on 5/7/24 at 2:10 PM identified that she was Resident #4's nurse and she had a total of 26 residents on her floor with 2 NA. She further identified that NA #1 did not notify her that she could not provide care for Resident #4, if she had been notified she would have called the supervisor. 2. Resident #5 had a diagnosis of dementia. A care plan dated 4/5/24 identified that the resident was at risk for pressure ulcers related to inability to respond to pressure related discomfort, impaired mobility, and bowel and bladder incontinence with interventions that included position changes every two (2) hours and incontinent care per facility protocol. An admission Minimum Data Set (MDS) dated [DATE] identified that the resident had severely impaired cognition, required total care with activities of daily living (including bed mobility), was always incontinent of bowel and bladder, had moisture associated dermatitis(skin inflammation caused by prolonged exposure to moisture), and was at risk for pressure ulcers. Observation on 5/6/24 at 11:45 AM identified that a family member had approached the nurse's station with concerns about Resident #5 on whether or not the resident had received morning care as the resident was still in bed in a johnny. Interview with Nurse Aide (NA) #6 on 5/6/24 at 11:50 AM identified that he/she had Resident #5 on her assignment and had provided incontinent care and repositioning at approximately 8:30 AM that morning. NA #6 further identified that she had a very busy morning with an assignment of 15 residents and only one other NA on the floor. The reason Resident #5 was still in bed at 11:45 AM and had not received incontinent care and positioning since 8:30 (3 hours and 15 minutes) was that the resident required assistance of 2 people and she had not had an opportunity to get back to the resident with a second NA #6 also had 15 residents on her assignment. Interview with LPN # 6 identified that she was Resident #5's nurse for the 7:00 AM to 3:00 PM shift and the census on the unit was 30, and had 2 NA. She was unaware that the NA's were having difficulties completing their assignments. Interview with the nursing supervisor on 5/6/24 at 1:00 PM identified that if she had been notified that the NA's were having difficulty completing the assignment, she would have made adjustments to the staffing. Interview with the Director of Nurses on 5/6/24 at 2:00 PM identified that if the NA were having difficulty with their assignment they should have let the charge nurse/supervisor know. Additionally the resident should have been turned and repositioned and given incontinent care every 2 hours.

Based on clinical record review, facility documentation, and interviews, for one (1) of three (3) residents reviewed for dining, (Resident #4), the facility failed to ensure that a dietary restriction was followed. The finding includes. Resident # 4 had a diagnosis of dementia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment, was dependent on staff for all ADL's. A care plan dated 4/7/24 identified that that the resident had an alteration in nutrition related to fluctuating intake with interventions that included to provide the diet as ordered and to assist with meal intake. Review of physician's orders identified an allergy to lactose (a sugar found in milk) A physician's order dated 5/1/24 directed to provide a puree diet with thin liquids (may have soft foods such as pasta). Review of a meal ticket on 5/6/24 identified that the resident was on a lactose free diet, puree with thin liquids. Observation on 5/6/24 at 12:30 PM identified NA #4 feeding Resident #4 seafood alfredo and thrive ice cream. Interview with NA #4 on 5/7/24 at 1:59 PM identified that she knew that the resident had was not supposed to have lactose and did not think the alfredo or thrive had lactose. Interview with the cook on 5/7/24 at 1:56 PM identified that the alfredo sauce is made with lactaid milk (lactose free), parmesan cheese, and butter. The cook further identified that parmesan cheese and butter have small amounts of lactose. Interview with dietary aide #1 on 5/7/24 at 2:00 PM identified that he had read the meal ticket to the cook on 5/6/24 for Resident #4, however, he was unaware that the alfredo sauce had lactose. Further, he served the resident the thrive ice cream because he thought it was lactose free, however, observation identified that the first two ingredients were milk and cream. Interview with the Head [NAME] on 5/7/24 at 3:00 PM identified that the resident should not have been served the seafood alfredo or the thrive ice cream.

Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews, for three of six sampled residents (Resident #7, Resident #55, and Resident #392 ) reviewed for accidents, the facility failed to ensure the resident was transferred per the plan of care and/or that the wheelchair was maintained to prevent an accident and/or ensure measures were in place to prevent a fall and/or transfer a resident in accordance with the care plan in accordance with the physician's orders [REDACTED]. a. Resident #7's [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified that Resident #7 was without cognitive impairment and required extensive assistance of two people for transfers. Review of the Activities of Daily Living (ADL) care plan dated 2/14/19 identified that Resident #7 required total/extensive assistance with ADL's secondary to dementia with interventions that included transfer with assist of two with pivot disk, resident is non-ambulatory. Review of the (MONTH) 2019 physician's orders [REDACTED]. The nurse's note dated 3/25/19 at 8:17 PM noted a skin tear measuring 12cm x 0.5cm x 1cm on the left outer aspect of leg with a category 3 tissue loss, moderate amount of blood noted. Further review identified that the incident occurred during a transfer from wheelchair to bed and the physician directed to send resident to the hospital. The hospital record dated 3/25/19 identified Resident #7 received 17 sutures to the laceration on the resident's left lower leg. Review of the reportable event form summary dated 3/27/19 identified that Nurse Aide (NA) #1 removed the leg rests on the wheelchair, and transferred the resident from wheelchair into the bed and noticed the resident's leg had an injury. Further review identified that the wheelchair leg rest had a 3-4 inch screw that was protruding and the wheelchair was removed from service for repair. Interview with NA #1 on 5/13/19 at 11:30 AM identified he/she removed the leg rests and transferred the resident to the bed without the benefit of another person, gait belt, or the pivot disk. NA #1 further identified that he/she did see the screw on the chair and did not use the pivot disc because he/she did not know what it was and/or was not trained on how to use it prior to the incident. NA #1 further identified that he/she should have reviewed the care plan prior to transferring the resident but did not. Interview with the Director of Nurses (DNS) on 5/13/19 at 11:45 AM identified it is his/her expectation that the NA reviews the NA care plan before caring for a resident and that the resident required a two person assist with transfers. The facility failed to ensure measures were in place to safely transfer the resident. b. Resident #55's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified Resident #55 with severely impaired cognition, with no behaviors exhibited, required limited assistance with transfers, walking in room, and toilet use, was not steady while moving from seated to standing position, walking, or turning around, and sustained 2 falls without injury since the last assessment dated [DATE]. physician's orders [REDACTED]. The Resident Care Plan (RCP) dated 1/24/19 identified Resident #55 was at risk for falls. Interventions included to offer Resident #55 to participate in recreational activities, educate resident to ask for help/assistance with anything, and to encourage the resident to use the call bell for assistance. Review of the Reportable Events (RE) identified the following: On 6/11/18 Resident #55 was found on the floor, no injury noted. A new intervention was implemented to ensure the resident was positioned in the center of the bed. On 9/28/18 Resident #55 was found on the floor, no injury noted. A new intervention was implemented to encourage the resident to use the call bell for assistance. On 11/15/18 Resident #55 was found on the floor, no injury noted. A new intervention was implemented to educate the resident to ask for help/assistance with anything. The Nursing Event report dated 12/30/18 identified Resident #55 was found on the floor, no injury was noted. Physical Therapy (PT) evaluation and plan of treatment dated 1/7/19 identified Resident #55 was noted with increased difficulty with gait and transfers per nursing, resident exhibits impaired safety awareness due to cognitive deficits. Clinical impression resident has shown a decline in transfers and gait compared to previous assessment. Exhibits decreased safety with gait and transfers presenting a possible fall risk. Would benefit from skilled PT for resident to be able to return to prior functional level of gait and transfers independently in room. Recommend skilled physical therapy 5 times a week for 4 weeks, with a goal to be able to ambulate safely. The Nursing Event form dated 1/15/19 identified Resident #55 was found on the floor, no injury was noted. The new intervention noted was to offer me to participate in recreational activities. The RE dated 1/25/19 at 6:15 PM identified Resident #55 was found on the floor on his/her left side complaining of left leg pain. The physician was notified and directed to send to the emergency room for evaluation. Resident #55 was admitted to the hospital and diagnosed with [REDACTED]. Interview and review of the clinical record with PT #1 5/19/19 at 12:30 PM identified Resident #55 was evaluated by physical therapy on 1/7/19 after nursing noted a decline in ambulation and transfer status. Additionally, at the time of Resident #55's fall on 1/25/29 Resident #55 required contact guard/supervision for ambulation, and should not have been ambulating independently. The facility failed to ensure measures were in place to prevent a fall. c. Resident #392's [DIAGNOSES REDACTED]. The admission nurse's note dated 11/12/18 at 3:57 PM identified Resident #392 was alert and oriented to person, place and time and required daily skilled nursing. The note indicated upon assessment Resident #392 had ecchymotic areas to the left side of the abdomen, the back, the arm, thigh and lower back from a fall at home. The Resident Care Plan (RCP) dated 11/12/18 identified the resident was a risk of falls because of a history of falls, weakness, and impaired mobility. Interventions directed to transfer and ambulate per adult daily living skills care plan, use the call bell when assistance is needed, and put the bed in a low position when the resident was in bed. The admission Minimum Data Set assessment dated [DATE] identified Resident #392 had no memory or cognitive impairments, required extensive two (2) person assistance with for repositioning while in the bed and transfers in and/or out of the bed and chair and the resident's balance during transitions and walking was not steady and only able to stabilize with staff assistance. The Occupational Therapy Treatment Encounter Note dated 12/3/18 identified nursing approached the therapist as the resident could not get off the toilet. The note indicated an attempted sit to stand from the toilet with the assist of two (2) times two (2) trials but Resident #392 was not extending at hips and knees and was unable to stand. The note identified the arm of the wheelchair was removed and the resident completed a squat pivot transfer into the wheelchair with the maximum assist of three (3) people. Resident downgraded to Hoyer lift transfer. A physician's orders [REDACTED].#392 with a Hoyer, mechanical lift, per the facility policy. The Reportable Event Form dated 12/6/18 at 11:00 AM identified two (2) nurse aides were transferring the resident from the toilet to the wheelchair and when Resident #392 stood up the resident's legs buckled during the transfer and Resident #392 was immediately helped back into the wheelchair. The report indicated Resident #392 did not touch the floor and the resident did not sustain any injuries. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #4, on 5/14/19 at 1:35 PM she indicated that she was not assigned to Resident #392 on 12/6/18 and NA #8 was assigned to the resident. NA #4 stated NA #8 had asked for assistance getting Resident #392 off of the toilet. NA #4 identified her and NA #8 had the gait belt on the resident and were assisting Resident #392 off of the toilet to the wheelchair and during the transfer, the resident's legs buckled. NA #4 stated they were able to get the resident into the wheelchair without the resident going to the floor. Interview with the Occupational Therapist (OT) #1, on 5/14/19 at 2:45 PM indicated she was the therapist working with Resident #392 from 12/3/18 through 12/10/18. OT #1 stated the therapy department started therapy with Resident #392 on 12/3/18 due to a decline in transfer ability. OT #1 identified she was the therapist on 12/3/18 when the resident could not transfer off of the toilet. OT #1 stated the resident during the time of the 12/6/18 incident in the bathroom was a Hoyer lift due to the resident's legs buckling when standing and transferring. OT #1 indicated any resident who is a Hoyer lift should not be utilizing the toilet in the bathroom. NA #8 was not available for an interview. Review of the facility Job Description for Certified Nursing Assistant directed that the major duties and responsibilities included to participate in planning and following current resident's care plans on all residents under his/her care.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 11 residents (Resident #125, 333 and 25) reviewed for accidents, the facility failed to provide physical assistance and/or supervision, as ordered by the physician, to prevent accidents with resulting serious injuries. The findings include: 1. Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 1/18/17 identified Resident #125 was at risk for falls due to a history of falls, and was at risk for fractures related to risk for falls. Interventions directed to encourage the family members to notify staff before leaving the resident, and observe for any dizziness or unsteady gait when ambulating. Additionally, the care plan identified the resident was at risk for alteration in ADL's, and required total assistance due to Alzheimer's dementia. Interventions directed to transfer Resident #125 with assistance of 2 with the rolling walker, and to ambulate Resident #125 with assistance of 2 with the rolling walker. A physician's orders [REDACTED].#125 with the rolling walker and the assistance of 2, and ambulate with the rolling walker and assistance of 2. The quarterly MDS dated [DATE] identified Resident #125 was severely cognitively impaired, required extensive assistance of 2 with transfers, toilet use and extensive assistance of one person with personal hygiene. Additionally, the MDS identified Resident #125 had falls since admission and/or prior assessment, and had 1 fall with injury since admission and/or prior assessment. Further, the MDS identified Resident #125 was not steady moving on and off the toilet, and was only able to stabilize with staff assistance. A reportable event form dated 9/29/17 at 2:30 PM identified Resident #125 fell in the bathroom. The investigation indicated that NA #6 and Person #5 (Resident #125's family member) assisted Resident #125 to the bathroom and put him/her on the toilet. Further, the investigation indicated that Person #5 asked NA #6 to leave the bathroom to go get blankets. In addition, the investigation indicated that Resident #125 was left in the bathroom with Person #5, who also walked away and left Resident #125 alone in the bathroom. Resident #125 fell off the toilet. The nurse's note dated 9/29/17 at 4:06 PM identified that Resident #125 was found in his/her bathroom laying on right side. Further, the nurse's note identified that Person #5 was present during fall, and stated he/she stepped out for 1 min and left Resident #125 alone in the bathroom, and then noticed Resident #125 had fallen. Additionally, the nurses note identified that x-ray of right hip was ordered. The nurse's note dated 9/29/17 at 4:19 PM identified Resident #125 was observed on floor in the bathroom. Person #5 indicated he/she went to look in Resident #125's closet and heard the resident fall in the bathroom. Further the nurse's note identified that Person #5 was educated to not leave Resident #125 alone in the bathroom. The nurse's note dated 9/30/17 at 8:43 AM identified based on the radiology report, Resident #125 sustained a non-displaced right transcervical femur fracture. Subsequent to physician notification, Resident #125 was sent to the hospital. Review of radiology report dated 9/30/17 identified a non-displaced right transcervical femur fracture. Interview with PT #1 on 4/17/18 at 1:10 PM identified Resident #125 should not have been left alone in the bathroom with Person #5. Resident #125 should have had nursing staff with him/her in the bathroom for safety. Further, PT #1 indicated that Resident #125 required assistance of 2 staff for transfer and ambulation and should not have been left alone in the bathroom because of her cognition. Interview with OT #2 on 4/17/18 at 1:15 PM identified that Resident #125 should not have been left alone in the bathroom with Person #5, and the nursing staff should be with Resident #125 in the bathroom for safety because of Resident #125's cognition. Although the physician order [REDACTED].#125 with the rolling walker and the assistance of 2, and ambulate with the rolling walker and assistance of 2, Interview with the ADNS on 4/17/18 at 2:30 PM identified that it was safe to leave Resident #125 in the bathroom with Person #5, even though Person #5 walked out of the bathroom and left Resident #125 alone on the toilet because Person #5 was very involved. A phone interview with NA #6 on 4/17/18 at 3:15 PM identified Person #5 and NA #6 were in the bathroom with Resident #125 when Person #5 asked NA #6 to go get some towels. Further, NA #6 identified that Person #5 ensured NA #6 that he/she will not leave Resident #125 alone in the bathroom. In addition, NA #6 identified that when NA #6 returned with the towels, Resident #125 was in the floor. Further, NA #6 identified that Resident #125 was not be left alone in the bathroom and NA #6 did not ask if it was safe for Resident #125 to be left in the bathroom with Person #5. In addition NA #6 identified that he/she was educated not to leave a resident with anybody but the nursing staff, not a family member. Review of facility documentation identified that NA #6 was educated on 9/30/17 to not leave resident alone in the bathroom and if resident was an assistance of 2 people, 2 people stay in bathroom with resident at all times. Review of facility fall prevention management policy directed to provide environment free of accident hazards and by assisting each resident to attain or maintain his/her highest level of function by providing adequate supervision, assistive device and functional programs as needed to prevent falls. The facility failed to ensure Resident #125 had supervision while on the toilet which resulted in a fall and a femur fracture. 2. Resident #333 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record indicated on 10/23/17 Resident #333 was sent to the hospital for left leg pain, and to monitor the left groin and left calf surgical wound. Resident #333 was readmitted back to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An APRN note dated 11/1/17 indicated Resident #333 was sent to the hospital for a left groin infection, status [REDACTED]. A laboratory report dated 11/1/17 indicated Resident #333's red blood cell (RBC) level was 2.50 g/dl (normal range 4.00-5.00 g/dl) noted as low, the hemoglobin (Hgb) was 7.4 (normal range 12.1-15.7 g/dl) noted as critical, and the hematocrit (Hct) was 23.4 g/dl (normal range 35.0-45.0 g/dl) noted as critical. An admission MDS dated [DATE] indicated Resident #333 had no cognitive deficits, required extensive assistance of two for transfer, extensive assistance of one for walking in the room, and limited assistance of one person for walking in the corridor. A resident care plan dated 11/7/17 identified Resident #333 was at for falls secondary to an unsteady gait and at risk for fractures related to bone age. Interventions included to observe for dizziness or unsteady gait when ambulating. In addition, the care plan identified Resident #333 required extensive assistance with care secondary to extensive wounds. Interventions included transfer with assistance of 1 with a rolling walker, ambulate with assistance of 1 with rolling walker for 200 feet or to tolerance, and ambulate with nursing twice a day. A physical therapy discharge summary dated 11/16/17 indicated Resident #333's standing balance was good, but the resident required supervised assistance on level surfaces. The resident's ambulation program included ambulate the resident 200 feet twice a day with assist of one and a walker. A physician's orders [REDACTED].#333 with assistance of one person with a rolling walker, and nursing to walk the resident 200 feet twice a day and with rolling walker and assistance of one person. Review of a laboratory report dated 11/29/17 indicated Resident #333's RBC level was 2.52, noted as low, the Hgb was 7.4 g/dl noted as critical, and the Hct was 23.4 g/dl noted as critical. An APRN note dated 11/29/17 indicated Resident #333 had a low Hgb and Hct. The resident denied any blood in the sputum, stool, or urine. Resident #333 denied any headaches, dizziness, weakness, abdominal pain, and/or nausea, vomiting, diarrhea or constipation. The assessment/plan section of the note indicated Resident #333's Hgb/Hct went from 8.2/26.4 g/dl to 7.4/23.4 g/dl, with no active signs of bleeding. The note indicated that the stool would be checked for blood 3 times, and an iron panel with CBC would be obtained. Staff were to continue to monitor. A physician note dated 11/30/17 indicated Resident #333 had a recent drop in Hct from 26.4 g/dl to 23.7. Resident #333 had no related gastrointestinal complaints, and the wounds were being followed closely by the wound team. The [MEDICAL CONDITION] was stable on current anticoagulants. The assessment/plan section of the note indicated the resident's [MEDICAL CONDITION] had improved from admission, but now had regressed back to his/her admission Hct of 23 g/dl. Iron studies would be drawn, and hemoccults would be obtained. The resident was on [MEDICATION NAME] for 2 weeks for gastric-protection to his/her dual anticoagulation. Supplemental iron would be added empirically. A laboratory report dated 12/1/17 indicated the resident's RBC count was 2.50, noted as low, the Hgb was 7.3 g/dl noted as critical, and the Hct was 23.4 g/dl noted as a critical. A nurse's note dated 12/1/17 indicated it was reported by staff that Resident #333 was on the floor outside. The nurse documented he/she arrived at the scene and Resident #333 was observed laying on his/her back on the floor in front of the entrance door on the left side, immobile, unconscious, and bleeding from his/her left ear. EMS was called immediately. The assessment showed Resident #333 pupils were fixed, the pulse was weak, the blood pressure was 124/80, and the heart rate was 54. Oxygen saturation was 98% on 2 liters of oxygen given for support. Resident #333 was transferred to the hospital for further evaluation. NA #4 who was with Resident #333 at the time of the fall indicated that he/she and the driver helped the resident get out of the car, NA #4 asked the resident to stand and wait for him/her to open the door, and the resident stood holding the walker. As NA #4 pressed the button on the right side to open the door, he/she heard a noise and observed Resident #333 fall on his/her behind, and went down on his/her back. The driver indicated he/she was retracting the ramp of the vehicle when he/she observed Resident #333 fall backward and hit his/her head. A hospital discharge summary dated 12/1/17 indicated Resident #333 was admitted status [REDACTED].#333 was reported to be alert after the incident and progressively declined in route to the emergency department. On arrival Resident #333's pupils were fixed and dilated. Resident #333 was intubated on arrival for airway protection. A CT scan of the head demonstrated a devastating [MEDICAL CONDITION] with a 1.5 cm midline shift and uncal herniation. Neurosurgery was consulted and agreed with terminal extubation in light of futility of care. Resident #333 was extubated at 9:20 PM, a [MEDICATION NAME] drip was started at 10cc/hour and the resident was pronounced dead at 10:05 PM. A reportable event form and investigation dated 12/1/17 at 3:30 PM indicated Resident #333 fell outside of the front entrance. Before the event Resident #333 was alert and oriented, and after the event the resident was noted to be unresponsive with his/her eyes open. EMS was notified and the resident was transferred to the hospital. The investigation indicated on 12/1/17 at approximately 3:30 PM, Resident #333 was returning from a doctor appointment via a taxi, and escorted by NA #4. Resident #333 was transferred safely with the help of NA #4 and the taxi driver down the ramp, and onto the left side of the door of the front entrance to the building. Resident #333 stood with his/her rolling walker in front of the doors as NA #4 walked away from the resident and attempted to press the button on the right side of the building to open the doors. NA #4 heard Resident #333 say woah, woah and as NA #4 turned and looked, Resident #333 was falling backwards and hitt his/her head on the sidewalk. NA #4 immediately checked the resident and called for help. An interview on 4/10/18 at 12:01 PM with NA #4 indicated he/she had escorted Resident #333 to a doctor appointment. He/she assisted Resident #333 with his/her walker into a taxi van via a ramp on the taxi van. He/she walked t Resident #333 onto the van instead of using a wheelchair because he/she was told by a nurse, who he/she could not recall, that Resident #333 needed to walk. NA #4 indicated when they returned from the doctor's appointment, the taxi van pulled up to the front entrance of the facility, and Resident #333 was assisted to the left side of the double doors. NA #3 indicated he/she instructed Resident #333 to stay there because the double doors swung outward. NA #4 left Resident #333 and went to the right side of the double doors to push the button to open the doors. As the button was about to be pushed, NA #4 indicated he/she heard Resident #333 say something. When NA #4 looked over at Resident #333, the resident was falling on to his/her bottom then fell backward on the concrete. NA #4 indicated he/she did not know how the resident fell , but the door did not make contact with the resident. NA #4 indicated he/she had a gait belt on Resident #333, but was not near the resident when the fall occurred. Additionally, NA #4 indicated he/she could not reach Resident #333. Although NA #4 indicated he/she had physically assisted Resident #333 off the taxi van, he/she left the resident standing alone while he/she went to push the button to open the door. A review of the clinical record and interview on 4/10/18 at 1:15 PM with Physical Therapist #1 indicated Resident #333 was discharged from physical therapy services on 11/16/18, and the status at the time of discharge was assistance of 1 with transfers, and ambulation 200 feet with assistance of one using a walker. PT #1 indicated all residents who require assistance, also require the use of a gait belt. He/she indicated the person assisting the resident needs to be close enough to hold on to the belt and/or at least have a hand covering the belt in case the belt needs to be used. Interview on 4/11/18 at 10:15 AM with LPN # 2 identified he/she was the nurse in charge of Resident #333 on 12/1/17 when the resident went to the doctors appointment. LPN #2 indicated the resident walked out and onto the taxi van with NA #4. LPN #2 indicated despite Resident #333's [MEDICAL CONDITION], the resident had no complaints of dizziness or weakness when he/she left the building. Additionally, despite the physician's orders [REDACTED].#333 with assistance of one person with a rolling walker, and for nursing to walk the resident 200 feet twice a day and with rolling walker and assistance of one person, LPN #2 indicated Resident #333 required assistance of 1 person only when he/she had a wound vac (vacuum assisted drainage for wounds) attached to him/her. LPN #2 further indicated that without the wound vac, the resident was more of a contact guard, and the resident did not have the wound vac when he/she went for the doctor's appointment on 12/1/17. LPN #2 indicated when NA #4 summoned for help he/she went outside and found Resident #333 lying on the ground to the left of the double doors. Resident #333's feet were near the door and his/her head was away from the door. An observation on 4/12/18 at 9:20 AM with the director of maintenance noted the left side of the double doors and button to open the doors on the right side of the double doors were 11 feet, 7 inches apart. A review of the clinical record and interview on 4/12/18 at 12:00 PM with the ADNS indicated that although a physician's orders [REDACTED].#333 with assistance of one person with a rolling walker, and nursing to walk the resident 200 feet twice a day and with rolling walker and assistance of one person, the ADNS indicated Resident #333 was independent when he/she did not have the wound vac attached. On 12/1/17 Resident #333 did not have the wound vac attached to him/her when he/she went to the doctors appointment. The ADNS was unable to provide documentation of a physician's orders [REDACTED].#333 mobility status was independent. An interview on 4/12/18 at 1:42 PM with PT #1 indicated a resident cannot have his/her mobility status changed (upgraded) by nursing and/or therapy without conducting a therapy evaluation prior to the change. PT #1 indicated Resident #333 did not have any subsequent evaluations after discharge from therapy on 11/16/17 to upgrade him/her from assistance of one for transfers and ambulation to independent ambulation. After surveyor inquiry on 4/12/18 the ADNS provided documentation of staff education dated 12/5/17 that indicated all residents care planned to receive assistance with their ambulation must be assisted closely by the care giver and a gait belt must be utilized on the resident during ambulation or transfer activity. The facility failed to provide the necessary supervision to Resident #333, according to the physician order, which resulted in a fall with a serious injury. 3. Resident #25's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated identified Resident #25 had severe cognitive impairments, required extensive two (2) person assistance with transfers and toilet use, was non-ambulatory, had functional limitation in range in motion of the upper and lower extremities on one side, utilized a wheelchair for mobility, and in the past ninety (90) days had one (1) fall with a minor injury. The resident care plan 11/15/17 identified the resident was at risk for falls and an alteration in activities of daily requiring extensive to total assist secondary to left side weakness, right side paralysis and right hand contracture. Interventions directed to wear a right foot ankle-foot orthosis for all transfers and extensive to total two (2) person assistance with transfers. The fall assessment dated [DATE] identified a score of eleven (11). The assessment identified that a score of ten (10) or higher represented a high risk for falls. The nurse's note date 1/2/18 at 10:49 PM identified the charge nurse was called into Resident #25's room. The note identified the resident was grimacing and said ouch with movement of the right upper arm, there was no deformity and/or shortening, Tylenol 650 milligrams was given and the Nursing Supervisor was notified. The nurse's note date 1/3/18 at 4:07 AM identified that at the beginning of the shift Resident #25 continued to complain of the right upper extremity pain, the arm was elevated on a pillow, and the resident had positive effects from the Tylenol received on the 3-11PM shift. At 2:00 AM Resident #25 was reevaluated for pain, the resident had positive range of motion to all major joints in the right upper extremity, there was no swelling to the joints, no discoloration was noted and a new order directed for occupational therapy. At 6:17 AM Resident #25 denied any further complaint of pain in the right upper extremity. The Advanced Practice Registered Nurse (APRN) progress note dated 1/3/18 at 1:11 PM identified Resident #25 was seen regarding a change in behaviors, fever and right shoulder pain. The assessment identified acute shoulder pain on extension, no rash or open area noted and the plan was to obtain an x-ray of the right shoulder to rule out a fracture. The addendum note identified the shoulder x-ray noted Resident #25 sustained an acute [MEDICAL CONDITION] humerus and the plan was to transfer the resident to the hospital for an orthopedic consultation. The nurse's note dated 1/3/18 at 3:11 PM identified a nurse aide informed the charge nurse in the morning, that she had lowered Resident #25 to the floor the day before on 1/2/18. The note identified upon assessment Resident #25 complained of right shoulder pain, was unable to lift the arm, the APRN was notified and examined the resident, an x-ray was obtained and subsequently Resident #25 was transferred to the hospital for further evaluation. The Reportable Event Form dated 1/3/18 identified the charge nurse was informed by a nurse aide that Resident #25 was lowered to the floor on the previous day 1/2/18. The incident took place in the shower room at approximately 2:50 PM. The investigation identified that a 7AM-3PM nurse aide observed Resident #25 sliding out of the wheelchair and the nurse aide helped to lower the resident to the floor. The investigation identified that two (2) nurse aides assisted Resident #25 back into the wheelchair, the resident was okay and Resident #25 was returned to his/her room to watch television. The nurse aide explained she did not report the incident to the charge nurse because she did not know this was a fall. In a written statement the charge nurse identified that a nurse aide came to her on 1/3/18 stating Resident #25 was lowered to the floor on 1/3/18. The nurse's note dated 1/5/18 at 5:37 PM identified Resident #25 was readmitted to the facility status [REDACTED].#3, on 4/11/18 at 10:05 AM identified that she assisted with getting Resident #25 up off the floor and back into the wheelchair. NA #3 stated NA #2 was calling for assistance from the doorway of the shower room and when she entered the shower room, Resident #25 was on the floor lying on the right side. NA #3 identified NA #2 was changing or toileting the resident in the shower room alone. NA #3 stated she did not report the incident to the charge nurse because she thought that NA #2 had reported the incident. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #2, on 4/11/18 at 11:47 AM identified she had taken Resident #25 into the shower room was trying to change the resident's incontinent brief. NA #2 stated that someone had put a pillow behind the resident's back which made Resident #25 slide out of the wheelchair onto the floor. NA #2 identified she called for help to get the resident back into the wheelchair and did not call the charge nurse prior to moving Resident #25. NA #2 stated she did not report the incident to the charge nurse on 1/2/18 because she did not realize lowering a resident to the floor was a fall and she should have informed the charge nurse. Interview with the Assistant Director of Nursing (ADON) with the Director of Nursing (DON) present on 4/12/18 at 9:05 AM identified that neither nurse aide reported the 1/2/18 incident until 1/3/18. The ADON identified that NA #2 should have had another nurse aide with her when she took Resident #25 into the shower room to check for incontinence. The ADON stated NA #2 was terminated because of the incident.

Based on clinical record review and interviews for 1 of 4 sampled residents (Resident #69) reviewed for falls, the facility failed to provide the necessary supervision to prevent an accident. The findings include: 1. Resident #69 ' s [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified severe cognitive impairment, did not ambulate and required extensive assistance of two staff members for transfers and toilet use. The care plan dated 11/2/12 and a review of the resident care card directed Resident #69 was to be transferred with the assistance of two utilizing the stand pivot method. A physician's order [REDACTED]. A review of the facility's accident and incident report dated 1/6/13 and a review of nurses' notes identified on 1/6/13 at 8:40 PM Resident #69 was being transferred from the toilet to the wheelchair with the assistance of one (nurse aide #2) at which time Resident #69's knees buckled resulting in the resident being lowered to the floor. The nurse's note dated 1/6/13 at 11:00 PM identified Resident #69 was observed with the right leg under the right buttock and the left leg stretched out in front of the resident. Upon assessment Resident #69 complained of severe pain in the right knee and right ankle when attempts were made to move the right lower extremity and there was decreased range of motion in the lower extremity. The physician was notified and directed to transfer Resident #69 to the emergency department for an evaluation. Resident #69 was diagnosed with [REDACTED]. Interview with NA #2 on 7/8/13 at 2:00 PM identified he/ she transferred Resident #69 without the assistance of another staff member. The nurse aide further identified that it was his/ her first day off of orientation and he/she had not previously been assigned to the unit. NA#2 identified that he/ she was aware that he/she should check the resident's care card prior to providing care but had not reviewed it thoroughly regarding the amount of assistance the resident required for transfers.

Based on clinical record review and interviews for 1 of 3 sampled residents reviewed for accidents (R#19), the facility failed to transfer the resident via Hoyer lift. The findings included: Resident #19 was admitted to facility on 4/5/2011 with [DIAGNOSES REDACTED]. Physician's/Therapy orders dated 9/23/12 directed PT evaluation and treatment, 5 times a week, for eight weeks (9/23/11 to 11/18/11) and a mechanical lift via a Hoyer with assistance of two (2) for transfers. PT progress notes dated 11/02/2011 identified that a family member reported witnessing R#19 being transferred by one (1) staff person in the facility. The progress note identified that PT #1's response to the family member was that according to the plan of care the resident required a Hoyer lift with assistance of two (2) for all transfers. Review of PT discharge note dated 11/03/11 identified R#19 refused to participate and/or refused to get out of bed and so due to lack of significant progress and decreased willingness to participate, the resident was discharged from therapy. Physicians/Therapy discharge orders dated 11/08/11 signed by PT#1 and APRN #1, directed to discharge R#19 from therapy due to refusals. However, the therapy orders failed to identify the resident's transfer status. The RCP dated 12/20/11 identified a problem with risk for falls with intervention added on 4/20/12 that included transfers via Hoyer lift and assistance of two (2). A quarterly MDS dated [DATE] identified the resident as moderately cognitively impaired and totally dependent, requiring full staff performance for transfers between surfaces, i.e. from bed to chair. Review of facility Accident/Incident report dated 1/30/12 at 1:00 PM identified that R#19's left lower extremity was extremely swollen, warm and painful when touched. It further noted that an x-ray identified a fracture of the proximal tibia and fibular metadiaphyses with mild displacement. Further review of the facility's investigation identified a copy of the Physicians/Therapy discharge order dated 11/8/2011 and signed by PT #1 and APRN #1 with the addition of the transfer status as maximum assist of two (2) for a stand/pivot transfer. Interview and review of R#19's original and amended 11/8/2011 PT discharge orders with APRN #1 on 6/7/12 at 9:58 AM indicated that she was unaware of the changes made to the therapy orders and would expect that after an actual therapy evaluation was completed new orders to be written, if there was a change in transfer status. Interview with the Radiologist, MD #1, on 6/7/2012 at 10:30 AM identified that although he could not say what caused R#19's fracture, his impression of the radiological report dated 1/30/12 was that the fracture was subacute and suspected the fracture was there for one to two weeks. Interviews with NA#3, NA#4, NA#5 and the Unit Manager, RN#3, on 6/07/12 at 2:05 PM identified that in January, 2012, R#19 was transferred via stand pivot and the maximum assistance of two (2) persons. Interview with PT#1 on 6/08/12 at 8:04 AM identified that when R#19's was discharged from therapy on 11/8/2011 the resident's transfer status was mechanical lift (Hoyer) transfer with assist of two. She indicated that although R#19 did transfer stand/pivot in a controlled environment with therapist, she felt she could not teach the facility nurse aides to safely transfer R#19 via stand/pivot on a daily basis. She identified that the original discharge orders dated 11/8/2011 did not have a transfer status indicated because there was no change from R#19's original transfer status as a mechanical lift (Hoyer). She further indicated that those same orders she signed, dated 11/8/11 were changed with the added (SPT with maximum assist of 2) without her knowledge. Interview with PT#2 on 6/08/12 at 8:32 AM he indicated that after R#19's 1/30/12 fracture of the proximal tibia and fibular metadiaphyses was identified, a request was made for PT#2 to review R#19's clinical record. Clarification was requested because R#19's transfer status was not clear on the 11/8/2011 therapy discharge orders. He indicated that based on that record review he added the stand/pivot maximum assist of two transfer status by writing on the 11/8/2011 orders. However, he did not change the date on the order to reflect the date the transfer status was added. Interview with the Director of Nurses on 6/08/12 at 10:34 AM and review of R#19's clinical record and other facility documentation identified that R#19's fracture was investigated as an injury of unknown origin and although unable to explain the changes in the physicians orders, indicated that the change in transfer status may have been communicated via morning report and/or verbally by PT#2. Interview with OTR/L #1 on 6/11/12 at 1:10 PM and review of therapy documentation identified that at the end of therapy on 11/7/2011 R#19's status was maximum assist of 2 for Hoyer lift transfers. She indicated that after a review, it was identified that the 11/8/2011 therapy order were changed and in different handwriting with a star next to the transfer section noting maximum assist of 2 stand/pivot transfers (SPT). She further identified that PT#2 reported that on 2/02/12 he had added maximum assist SPT to the original order.

Based on review of the clinical record, observation and staff interview for two of four sampled residents (R#74 and R#109) reviewed for pressure ulcers, the facility failed to implement preventative measures. The findings include: 1. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An initial nursing assessment dated [DATE] identified the resident as a status [REDACTED]. A Braden Scale dated 11/23/10 identified the resident a moderate risk for pressure ulcers. A nurse's note dated 11/25/10 identified the resident remained on bedrest. A nurse's note dated 11/26/10 identified the resident with a left heel intact blister and 4.0 centimeter (cm) left lateral calf fluid blister. A care plan dated 11/29/10 identified an alteration in skin integrity related to a deep tissue injury/blood filled blister on the the left heel. A physician's orders [REDACTED]. Review of the clinical record failed to reflect an assessment of the left heel until 11/29/10 by the advanced practice registered nurse (APRN) who documented and identified a 4.0 cm by 4.0 cm deep tissue injury (DTI) on the left heel which started as a blood filled blister and was dark red purple in color. Review of APRN documentation on 4/20/11 identified the left heel as an unstageable pressure ulcer which measured 3.0 cm by 4.0 cm with eschar. Observation on 4/21/11 at 10:15 AM noted the left heel had a circular necrotic black eschar approximately quarter size, with an adjacent hard scab brownish in color. Review of the Facility Pressure Ulcer Prevention Policy identified bed bound residents were at risk with intervention that should include the use of lifting devices to relieve pressure under heels. Interview with LPN#1 on 4/20/11 at 1:15 PM and review of the clinical record and facility prevention policy identified that the facility failed to provide interventions for prevention of heel blisters on admission (i.e. off loading) as per facility policy. 2. Resident # 109's [DIAGNOSES REDACTED]. A MDS dated [DATE] identified the resident as moderately cognitively impaired and requiring extensive assistance of two staff members for bed mobility and transfers. A nursing admission assessment dated [DATE] identified the resident had 9 staples to the right hip area, reddened buttocks, various systemic bruising and intact heels. A nurse's note dated 8/24/10 identified that the physician noted a right heel deep tissue injury (DTI) and directed skin prep to both heels twice daily for 21 days, heel lift boots to bilateral extremities at all times and multivitamin on by mouth daily. A wound tracking dated 8/25/10 identified a Deep Tissue Injury/fluid filled purple blister to the right heel, etiology of pressure, and measured 4.0 cm by 1.0 cm. On 9/13/10 the right heel was identified 50 percent slough and measured 5.0 cm by 4.0 cm. The treatment was changed to wound cleaning followed by Santyl to eschar followed by [MEDICATION NAME] and dry clean dressing. On 3/10/10 the right heel was noted as healed. Review of the plan of care of care, nurses notes, treatment administration records and nursing assessments from 8/18/10 to 8/24/10 with Registered Nurse #1 failed to reflect that interventions were implemented to prevent heel breakdown on an immobilized resident. Although a care plan dated 8/19/10 identified the resident with a problem with mobility and at risk for skin breakdown the care plan failed to address heel off loading. RN#1 indicated that the resident was to have been provided off loading of heels and a skin prep to the heel due to immobilization. Review of facility policy for pressure ulcer prevention identified that immobile residents were at risk for breakdown with interventions that included to utilize lift devices under heels.