Every finding on record at Marquette

Based on interview and record review, the facility failed to provide written notices of discharges to resident representatives or notices to the ombudsman for 3 of 3 residents reviewed for hospitalization and discharge. (Resident 3, 58 and 60) The deficient practice was corrected on 1/16/26, prior to the start of the survey, and therefore was past noncompliance.Findings include:1. The clinical record for Resident 3 was reviewed on 1/29/26 at 9:32 a.m. The diagnoses included, but were not limited to, pneumonia, atrial flutter, acute respiratory failure with hypoxia, malignant neoplasm of colon, and obstructive and reflux uropathy.A nursing progress note, dated 5/30/25 at 7:37 a.m., indicated the resident was transferred to the emergency room at 6:30 a.m. and the daughter was notified verbally. The note did not indicate the daughter received a written notice at any point after the transfer.During an interview, on 2/2/26 at 3:18 p.m., the Social Services Director indicated the facility went over transfers in the morning meeting and discussed people who were sent out. They brought the form to the meeting and added people to the form daily. The facility realized the family had only been given verbal notices and changed their process. The facility now gives written discharge notifications to resident representatives. They also made sure the Director of Nursing (DON) and Executive Director (ED) receive the ombudsman list which was sent.2. The clinical record for Resident 58 was reviewed on 2/2/26 at 9:48 a.m. The diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, catatonic disorder due to a known physiological condition, mood affective disorder, type 2 diabetes mellitus, edema, and metabolic encephalopathy. A physician's order, dated 1/5/26, indicated to send the resident to the hospital for a psychiatric evaluation.A nursing progress note, dated 1/5/26 at 2:37 p.m., indicated the resident had a Zoom visit with a psychiatric physician who ordered the resident to be sent to the hospital. The resident was transported by the family.A transfer/discharge report, dated 1/5/26, indicated Resident 58's son was notified of the transfer. It did not indicate a written report, or the bed hold policy was provided to the resident representative.During an interview, on 2/2/26 at 12:02 p.m., the ED indicated Resident 58 was part of the facility's plan of correction implemented prior to the start of this survey. The resident's representative was notified verbally and had received the bed hold policy upon admission; however, the representative had not been given a written transfer/discharge form or another copy of the bed hold when the resident was transferred to the hospital for a psychiatric evaluation on 1/5/26.3. The clinical record for Resident 60 was reviewed on 2/2/26 at 11:51 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy, contusion of the right thigh, acute and chronic respiratory failure with hypoxia, pulmonary fibrosis, bronchiectasis, acute on chronic diastolic congestive heart failure, anxiety disorder, and moderate dementia with mood disturbance.A progress note, dated 11/24/25 at 1:12 p.m., indicated the resident was discharged at 1:00 p.m. to her assisted living memory care apartment.A social services progress note, dated 11/21/25 at 1:46 p.m., indicated the resident was going to discharge to memory care on 11/24/25 per her request.During an interview, on 1/30/26 at 11:15 a.m., the ED indicated the facility had discovered an issue with written transfer and discharge notifications to the resident representatives, bed hold policy, and ombudsman notifications and had completed a plan of correction on 1/13/26. The resident representative had not received a written notice of transfer or the bed hold policy. Audits and staff education was completed on 1/16/26. The ombudsman was not notified of the emergency transfer to the hospital until the oversight was discovered. The plan of correction was completed on 1/16/26.During an interview, on 2/2/26 at 12:04 p.m., the ED indicated the facility had only been notifying the ombudsman of emergent discharges and had not notified the ombudsman of Resident 60's scheduled discharge. This occurrence was already noticed and corrected with the plan of correction the facility had implemented prior to the start of this survey.A current facility policy, titled Transfer Emergency Discharge, undated and provided by the ED on 1/30/26 at 3:26 p.m., indicated .When a resident is temporarily transferred to an acute care facility, a notice of transfer is provided to the resident and resident representative as soon as practicable.The facility notifies the resident, his or her representative, and the representative of the Office of the State LTC Ombudsman in writing of the discharge, including notification the resident has the right to appeal a transfer or discharge.The notice to the representative of the Office of the State LTC Ombudsman is sent at the same time the notice is provided to the resident.The deficient practice was corrected by 1/16/26, after the facility completed house wide audits, the staff were educated, and the policy was updated.3.1-12(a)(6)(A)(ii)3.1-12(a)(6)(A)(iv)

Based on observation, interview and record review, the facility failed to ensure hospital recommendations related to transfers were followed to ensure a resident was free of accidents for 1 of 2 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining an acute distal tibia fracture (a break in the lower end of the tibia, often near the ankle joint). Findings include: During an observation, on 6/10/25 at 10:43 a.m., Resident B was sitting in a wheelchair, her right lower extremity was noted to be in a cast, and she was wearing a brace around her mid-section. A facility reported incident (FRI) indicated, on 5/21/25, the CNA assisted Resident B with ambulating to the toilet. During ambulation, the resident fell toward her right side and her right ankle appeared to roll. Resident B voiced complaints of right ankle pain. The clinical record for Resident B was reviewed on 6/10/25 at 10:20 a.m. The diagnoses included, but were not limited to, wedge compression fracture of third lumbar vertebra, wedge compression fracture of second lumbar vertebra, and wedge compression fracture of T9-T10 vertebra. A preadmission hospital occupational therapist progress note, dated 5/16/25, indicated .Restrictions/Precautions .2 staff assist for safety . The equipment used during therapy was a gait belt and rolling walker. .PLEASE NOTE: If this patient is discharged from acute care prior to the next treatment session, this note will serve as the discharge summary indicating the patient's current functional status A preadmission hospital physical therapist progress note, dated 5/16/25, indicated .Restrictions/Precautions .2 staff assist for safety .Transfers .Stand Pivot .Moderate Assistance .Transfer Comment .With rolling walker from bed to chair .Gait .Distance 3 ft (feet) .PLEASE NOTE: If this patient is discharged from acute care prior to the next treatment session, this note will serve as the discharge summary indicating the patient's current functional status Resident B was admitted to the facility on [DATE]. A facility document, titled Pre-admission NEEDS ASSESSMENT, dated 5/20/25, indicated the resident was a fall risk and used a wheelchair, a walker, and was full weight bearing. A facility fall-risk assessment, dated 5/20/25, indicated the resident was chair bound. A Basic Interview for Mental Status (BIMS) assessment, dated 5/26/25, indicated Resident B had severe cognitive impairment. A nursing progress note, dated 5/21/25 at 4:59 p.m., indicated the nurse was called to the room and the resident was noted to be lying straight out on her back. The CNA reported Resident B stood with the walker, took a step, and began to fall toward the right. Resident B had her nonskid socks and her TLSO brace (a brace used to limit motion in the thoracic, lumbar, and sacral regions of the spine) on. There was no documentation in Resident B's clinical record to indicate more than one (1) staff member was present to assist Resident B. A typed statement from CNA 2, undated, indicated CNA 2 entered Resident B's room at approximately 2:20 p.m. The resident asked to use the restroom. A walker labeled Therapy was placed in front of Resident B. Resident B stood up, walked to the bathroom, used the bathroom, and washed her hands. On the way back to her recliner, the resident's ankle .folded towards her left ankle . and the resident fell. The CNA called out for help. The nurse responded with another nurse and another CNA. The resident was assessed and the three staff members transferred the resident, using a gait belt, to the bed. An x-ray report of the right ankle, dated 5/21/25, indicated Resident B had sustained an acute distal tibia fracture. During an interview, on 6/10/25 at 11:48 a.m., LPN 2 indicated when she arrived at the room on the day of the incident, Resident B was lying on the floor between her bed and the bathroom. The resident was laying on her back and she was wearing her TLSO brace. Resident B was assisted off the floor by three staff using a gait belt. During an interview, on 6/10/25 at 1:46 p.m., the Therapy Manager indicated Resident B had been evaluated by therapy the same day as the fall. Resident B was a moderate to maximum transfer to the wheelchair due to the resident's cognition. Resident B's gait (manner of walking/moving) was zero feet, and her wheelchair mobility was 10 feet. She indicated prior to the fall Resident B should have been in a wheelchair. During a telephone interview, on 6/10/25 at 1:51 p.m., CNA 2 indicated she had walked into the resident's room about 2:30 p.m., a walker was located beside the bedside table and in reach of the resident. The resident requested to use the bathroom. The CNA indicated she was going to get assistance from another staff member, but Resident B had already stood up. CNA 2 indicated she could not leave the resident and did not want to be direct with the resident. She did not know the resident or how Resident B would react. She assisted the resident to the bathroom. Once Resident B was finished and a couple feet away from her recliner, the resident fell towards her right, onto her right hip. CNA 2 indicated Resident B was using the walker and the CNA did not have a gait belt at that time. There was a walker and a wheelchair in the room. This was her first time assisting Resident B. She indicated the facility did have sheets which told the CNA's how to transfer residents, but there was no documentation related to Resident B on the sheet. During an interview, on 6/10/25 at 2:13 p.m., the Director of Nursing (DON) indicated the facility did encourage the use of gait belts. Prior to Resident B's fall and per the hospital, the resident was a moderate to max assist (50-75 percent of the work was completed by the care provider or assistive device). The facility would have initially used the hospital transfer status, received from the hospital in report. CNAs were educated on transfers upon hire and there were gait belts in every resident room. A current facility policy, titled Safe Lifting and Movement of Residents, dated as last revised July 2017 and received from the Director of Nursing on 6/10/25 at 3:19 p.m., indicated .In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents .Resident safety, dignity, comfort and medical conditions will be incorporated into goals and decisions regarding the safe lifting and moving of residents A current facility policy, titled ABUSE PREVENTION PROGRAM, dated May 2023 and received from the Director of Nursing on 6/10/25 at 3:18 p.m., indicated .Neglect is defined as failure of the facility, its employees or service providers, to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress 3.1-45(a)(2)

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNOC) document and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) document prior to the end of service date for 1 of 3 residents reviewed for beneficiary notification. (Resident 44) Findings include: The NOMNOC and SNF ABN documents for Resident 44 were reviewed on 2/4/25 at 8:50 a.m. a. The NOMNOC document indicated Resident 44's Medicare Part A coverage of services would end on 8/22/24 and Medicare would not pay for the current Medicare skilled services after the date of 8/22/24. The document indicated Resident 44 had the right to request an appeal. The appeal would need to be requested no later than noon of the day before the effective end of service date of 8/22/24. Resident 44 was provided with the NOMNOC document on 9/9/24, 13 days after the end of service date. b. The SNF ABN document indicated Resident 44's Medicare Part A Skilled coverage of services would end on 8/21/24 and beginning on 8/23/24, the services of Physical Therapy and Occupational Therapy would be out of pocket cost. Resident 44 was provided with the SNF ABN document on 9/9/24, 15 days after the end of service date. During an interview, on 2/3/25 at 9:09 a.m., the Social Service Director indicated therapy staff were out of town when Resident 44's beneficiary notices were due. The documents should have been provided to the resident 48 hours prior to the end of service date to give the resident time to appeal the decision. A current facility policy, titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated as last revised September 2022 and received from the Director of Nursing on 2/4/25 at 11:00 a.m., indicated .Residents are informed in advance when changes will occur to their bill .The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events .Termination-In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated .If the resident's Medicare covered Part A stay or when all of the Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form 10123) is issued to the resident at least two calendar days before benefits end 3.1-4(f)(1)(A) 3.1-4(f)(1)(B) 3.1-4(f)(2)

Based on observation, interview and record review, the facility failed to ensure privacy was provided during a medication administration for 1 of 1 resident reviewed for privacy. (Resident 19) Findings include: During an observation, on 1/30/25 at 10:41 a.m., Resident 19 was sitting in a wheelchair on her side of a shared room. QMA 5 was observed to administer eye drops to Resident 19. The privacy curtain had not been pulled to obscure the view of a visitor on the other side of the shared room. The visitor had an unobstructed view of the care being provided to Resident 19. At that time, QMA 5 indicated the privacy curtain should have been closed when providing all care. During an interview, on 2/4/25 at 3:19 p.m., the Director of Nursing indicated the facility followed the state and federal regulations. A current facility policy, titled Resident Rights, dated as revised in February 2021 and received from the Director of Nursing on 1/31/25 at 8:55 a.m., indicated .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to .privacy and confidentiality 3.1-3(p)(2) 3.1-3(p)(4)

Based on interview and record review, the facility failed to ensure care plan meetings were scheduled with the resident and/or resident's representative for 2 of 8 residents reviewed for care plan meetings. (Resident 36 and 37) Findings include: 1. During an interview, on 1/30/25 at 10:33 a.m., a family member for Resident 36 indicated they had not attended a care plan meeting for a year. The clinical record for Resident 36 was reviewed on 2/3/25 at 9:11 a.m. The diagnoses included, but were not limited to, severe dementia with mood disturbance, major depressive disorder, and mood disorder. The last documented care plan meetings were held on 3/14/24 and 6/28/24. 2. During an interview, on 1/30/25 at 10:29 a.m., a family member for Resident 37 indicated they had not had a care plan meeting in a year. The clinical record for Resident 37 was reviewed on 2/3/25 at 9:15 a.m. The diagnoses included, but were not limited to, age-related physical debility, constipation, and pain. The last documented care plan meeting was held on 5/6/24. During an interview, on 2/3/25 at 9:12 a.m., the Social Services Worker indicated care plan conferences were to be completed quarterly and a note was to be put into the medical record. During an interview, on 2/3/25 at 12:02 p.m., the Social Services Worker indicated she did not have any care plan notes for the missed care plan meetings. She did talk with the families and if they told her everything was o.k. or if they did not want a care plan meeting then she did not schedule a meeting. She was aware that a care plan meeting needed to be done, and the invite to the meeting needed to be sent to the responsible party/Power of Attorney and the resident. If they did not want to attend, she was to document the information. During an interview, on 2/4/25 at 3:19 p.m., the Director of Nursing indicated the facility followed the state and federal regulations. A current facility policy, titled Care Planning, dated as revised in March 2022 and received from the Executive Director on 2/3/25 at 1:34 p.m., indicated .The interdisciplinary team is responsible for the development of the resident care plans 3.1-35(a) 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure the physician was notified when blood sugars were out of the physician ordered parameters for 1 of 1 resident reviewed for quality of care. (Resident 34) Findings include: The clinical record for Resident 34 was reviewed on 2/3/25 at 1:32 p.m. The diagnoses included, but were not limited to, type 2 diabetes, edema, and chronic kidney disease. A physician's order, dated 7/8/24, indicated to obtain Accu Checks (blood sugar checks) 4 times a day and to call the physician when the blood sugars were less than 70 or greater than 400. A review of Resident 34's blood sugars indicated the following results: On 12/18/24, the resident's blood sugar was 69. On 12/28/24, the resident's blood sugar was 65. On 12/28/24, the resident's blood sugar was 425. On 1/5/25, the resident's blood sugar was 51. There was no documentation the physician was notified of the blood sugars which were out of the physician ordered parameters found in the resident's record. During an interview, on 2/4/25 at 3:18 p.m., the Director of Nursing (DON) indicated she could not find any notification for the blood sugars and the nurse should have notified the physician. During an interview, on 2/5/25 at 11:09 a.m., the DON indicated she could not find any notifications for the blood sugars in the record. A current facility policy, titled Charting and Documentation, dated as revised in 2017 and received from the DON on 2/4/25 at 3:17 p.m., indicated .Documentation of procedures and treatments will include care-specific details, including .notification of family, physician or other staff, if indicated 3.1-37(a)

Based on interview and record review, the facility failed to ensure staff obtained a resident's weight weekly to monitor for weight loss according to the physician's order and to correctly document the weights in the medical record for 1 of 3 residents reviewed for nutrition. (Resident 8) Findings include: The clinical record for Resident 8 was reviewed on 2/4/25 at 1:29 p.m. The diagnoses included, but were not limited to, Barrette's esophagus, anorexia, and nutritional deficiency. A nutritional note, dated 9/12/24, indicated the Registered Dietitian (RD) recommended to begin weekly weights for closer weight loss monitoring. A progress note, dated 9/12/24, indicated a new order had been placed for weekly weights. A physician's order indicated Resident 8 was to be weighed weekly in the morning, every Monday, for weight loss starting 9/16/24. A nutritional note, dated 11/7/24, indicated the RD would continue weekly weights for closer monitoring and would follow up with Resident 8's intakes, weekly weights, and labs as available. The resident's medical record was missing documentation for the weekly weights in the months of September, November, January, and February. A review of a weight summary indicated that the facility did not obtain weekly weights in the months of September, November, December, January, and February. During an interview, on 2/4/25 at 2:21 p.m., Licensed Practical Nurse 4 indicated when a resident had an order for weekly weights, the weights were documented on a form kept at the nurse's station and given to the unit manager when completed. During an interview, on 2/4/25 at 2:24 p.m., the Assistant Director of Nursing (ADON) indicated the weekly weight order should have been discontinued because Resident 8 was no longer followed by the RD. During an interview, on 2/4/25 at 3:18 p.m., the Director of Nursing (DON) indicated the resident was no longer being followed by the RD and the weekly weights should have been discontinued in October. She indicated the RD reviewed the note from 11/7/24 and acknowledged she documented to continue the weekly weights but given the stable weights the RD should have discontinued the order for the weekly weights. The order remained active, and the weights should have continued to be obtained according to the order. During an interview, on 2/4/25 at 3:39 p.m., the RD indicated the order for weekly weights should have been discontinued. The RD did not remove orders from the clinical record and noticed the order was still active when she visited Resident 8 in November. The RD documented to continue the weekly weights because the order was still active, and she thought the facility was still monitoring Resident 8's weights. A current facility policy, titled Nutrition Risk and Weight Loss Management, dated as last reviewed/revised February 2024 and received from the DON on 2/5/25 at 8:20 a.m., indicated .Nursing assistant or designated personnel will weigh residents per policy .Residents are weighed at least monthly unless there is a physician's order otherwise. The IDT or RD can request weights be completed weekly for monitoring as a nursing measure A current facility policy, titled Charting and Documentation, dated as revised 2017 and received from the DON on 2/4/25 at 3:17 p.m., indicated .Documentation in the medical record will be objective .complete, and accurate 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure a physician's order was clear and accurate related to the correct oxygen liter flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 10) Findings include: During an observation, on 1/31/25 at 9:58 a.m., Resident 10's oxygen flow rate was on 2-liters. The clinical record for Resident 10 was reviewed on 2/3/25 at 1:30 p.m. The diagnoses included, but were not limited to, chronic obstructed pulmonary disease (COPD), chronic respiratory failure, and essential hypertension. A physician's order, dated 1/8/25, indicated the oxygen flow rate was to be at 4 liters per minute via nasal cannula. The order summary indicated the oxygen flow rate was to be at 2 liters per minute via nasal cannula. The order had 2 different oxygen liter flow rates. During an interview, on 2/3/25 at 1:48 p.m., Licensed Practical Nurse (LPN) 3 indicated the oxygen order was not a titration order. She thought the resident was to be on 4 liters but did not see the 2 liters listed in the order summary. She would have to clarify the order because she was not sure. During an interview, on 2/3/25 at 1:55 p.m., the Director of Nursing (DON) indicated she was not sure what the oxygen flow rate was supposed to be, and she would have to check. During an interview, on 2/3/25 at 2:11 p.m., the DON indicated Resident 10 was supposed to be on 4 liters of oxygen. A facility policy, titled Oxygen Administration, dated as revised in October 2010 and received from the DON on 2/4/25 at 3:20 p.m., indicated .Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate per physician order 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure a two (2) handle cup was available for a resident's coffee for 1 of 1 resident reviewed for adaptive equipment. (Resident 1) Findings include: During an observation of the morning meal, on 2/3/25 at 8:35 a.m., Resident 1 was observed in the dining room. She had two handle cups for her milk, juice and water with lids, but an insulated cup with only one handle for coffee. During an interview, on 2/3/25 at 8:25 a.m., the Dietary Manager (DM) indicated she was aware the resident needed two (2) handle cups for her drinks, but she did not think about the coffee and the facility did not have a two-handle insulated cup. The therapy department indicated the resident needed two handle cups to hold the cup better. She would need to talk with management because the facility would need to order the cup. During an observation, on 2/5/25 at 8:33 a.m., Resident 1 was in the dining room eating her meal without assistance. She was noted to have milk, juice and water in two handle cups, but no coffee. During an interview, on 2/5/25 at 8:33 a.m., the Dietary Manager indicated Resident 1 did not have coffee because the facility did not have insulated cups with two handles and coffee could not be put in the regular two handle cups because the heat from the coffee could be felt through the cups. The clinical record for Resident 1 was reviewed on 2/5/25 at 8:53 a.m. The diagnoses included, but were not limited to, weakness, heart failure, and a need for assistance with personal care. A care plan, initiated on 12/5/24 and dated as last revised on 2/3/25, indicated the resident was at a nutritional risk and she was to use adaptive equipment to assist with feeding herself. A facility document, titled Occupational Therapy Treatment Encounter Note(s), with a date of service of 1/2/25 indicated an order was written for two handle mugs with lids to increase the resident's independence, oral intake, and to decrease spillage. A physician's order, initiated on 1/31/25, indicated 2 handle mugs with all meals. During an interview, on 2/4/25 at 1:06 p.m., the Therapy Manager indicated the resident was using two handle cups to promote independence with activities of daily living (basic self-care tasks performed daily such as eating). The resident was currently using two handle cups with no lids when she was discharged from therapy. A current facility policy, titled Activities of Daily Living (ADLs), Supporting, dated as revised in March 2018 and received from the Director of Nursing on 2/4/25 at 3:19 p.m., indicated .Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish 3.1-21(h)

Based on interview and record review, the facility failed to ensure documentation was complete and accurately reflected the care provided for 2 of 2 residents reviewed for accurate documentation. (Resident 46 and 1) Findings include: 1. The clinical record for Resident 46 was reviewed on 2/5/25 at 10:19 a.m. The diagnoses included, but were not limited to, insomnia, chronic kidney disease, and fever. A physician's order, initiated on 1/3/25, indicated to give Dayvigo (a medication used to treat insomnia) 10 milligrams at bedtime for insomnia. Documentation of the administration of the medication was not charted on 1/10/25 and 1/25/25. A physician's order, initiated on 1/3/25, indicated to monitor the resident's vital signs twice a day. Documentation of the treatment was not charted on the Medication and Treatment record for 1/31/25 for the second shift. 2. The clinical record for Resident 1 was reviewed on 2/5/25 at 8:53 a.m. The diagnoses included, but were not limited to, weakness, heart failure, and a need for assistance with personal care. A physician's order, initiated on 11/29/24, indicated to monitor for signs and symptoms of side effects from psychoactive drugs every shift and to notify the physician if side effects were present. There was no documentation for the monitoring found in the MAR/TAR for 12/5/24, 12/11/24 or 12/18/24 for the evening shift. A physician's order, initiated on 11/29/24, indicated to monitor for signs and symptoms of anti-coagulant medications (used to thin the blood) every shift. There was no documentation for the monitoring found in the MAR/TAR for 12/5/24, 12/11/24 or 12/18/24 for the evening shift. A physician's order, initiated on 11/29/24, indicated to assess the resident for pain every shift. There was no documentation for the assessment found in the MAR/TAR for 12/5/24, 12/11/24 or 12/18/24 for the evening shift. A physician's order indicated the resident was to be weight bearing (standing/walking) as tolerated on her bilateral lower extremities every shift. There was no documentation for the monitoring found in the MAR/TAR for 12/5/24, 12/11/24 or 12/18/24 for the evening shift. During an interview, on 2/5/25 at 9:19 a.m., the Assistant Director of Nursing indicated the facility determined a need to implement checking the documentation in the Medication and Treatment records due to missing documentation. A current facility policy, titled Charting and Documentation, dated as last revised in July of 2017 and received from the Director of Nursing on 2/4/25 at 3:17 p.m., indicated .The following information is to be documented in the resident medical record .Medications administered .Treatments or services preformed 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure dependent residents who required staff assistance with mobility and assistive devices, received adequate supervision and assistance to prevent falls and failed to ensure staff used a mechanical lift with assistance for 3 of 3 residents reviewed for accidents. (Resident C, B and H) This deficient practice resulted in Resident C being hospitalized for treatment of a blunt carotid artery occlusion injury and fractures of the neck, spine, left femur, and two fractures of the right foot. This deficient practice resulted in Resident B receiving a laceration with sutures to the right top of his head and to the right elbow. Findings include: 1. A facility reportable incident report, dated 6/24/23 at 11:01 p.m., indicated Resident C experienced a fall while showering in her restroom (assisted). Following the fall/shower, the resident was noted with increased pain/swelling to left knee and complaint of neck pain during the nursing assessment. The resident was transported to the hospital for further evaluation and treatment. A written statement of events, untitled, dated 6/24/23 and not timed, by Certified Nurse Aide (CNA) 4 indicated CNA 4 was giving Resident C a shower between 7:00 to 7:30 p.m. The resident was placed on the shower chair. The CNA turned around and took the soap off the paper towel dispenser. When the CNA turned around, the resident was slipping out of the shower chair. The CNA tried to rush to her and ended up slipping causing the chair to come off its legs and tilt backwards. The resident hit her head. CNA 4 placed her hand on the back of the resident's neck and the other under her thigh. The CNA positioned the resident back on the shower chair and noticed the resident had blood on the top of her head. CNA 4 continued to give the resident a shower and rinsed the blood from the resident's head. She then transferred the resident into her wheelchair and pushed the resident to the side of her bed. The CNA bumped the resident's knee on the bathroom door frame. CNA 4 dressed the resident and transferred the resident into her bed. The resident was complaining of pain. A written statement of events, untitled, undated, and not timed, by LPN 5, indicated LPN 5 went into the pantry to get applesauce and found CNA 4 putting ice in a small trash bag. The CNA explained it was for Resident C and the CNA thought she bumped the resident's leg on the doorway. LPN 5 went into the resident's room and asked the resident what happened. The resident indicated she fell . The nurse asked the CNA if she fell , and the CNA stated she did not fall. When LPN 5 was completing her assessment, she noticed a small bag of ice on the resident's neck and the resident's forehead was bleeding with a small hematoma. The clinical record for Resident C was reviewed on 1/16/24 at 10:06 a.m. The diagnoses included, but were not limited to, dementia, depression, and osteogenesis imperfecta (inherited disorder characterized by fragile bones). An admission Minimum Data Set (MDS) assessment, dated 3/23/23, indicated the resident was rarely/never understood. Her cognitive skills for decision making were severely impaired. She was dependent on staff for showering, bathing, and transfers. A care plan, initiated on 3/15/23, indicated the resident was at risk for falls. The interventions included, but were not limited to, educate on the importance of maintaining a safe environment, evaluate fall risk on admission and when needed, educate the resident and representative regarding the proper use of mobility devices, alert the provider if a fall occurred, and initiate frequent neuro checks and bleeding evaluation per the facility protocol. A nursing progress note, dated 6/24/23 at 10:00 p.m., documented as a late entry, indicated the nurse was informed by CNA 4 she bumped the resident's knee on the bathroom door after completing a shower when exiting the bathroom. The CNA indicated Resident C needed ice. LPN 5 asked the resident if she was okay, and the resident stated she fell . LPN 5 noted the resident had pain to the left knee, a small skin tear to the right upper arm with a small amount of bleeding, and the left hand was discolored. The nurse did a head-to-toe assessment and noted the resident had a hematoma with a small laceration on the forehead. A hospital report, dated 6/25/23 at 12:27 a.m., indicated the resident arrived at the emergency department by the Emergency Medical Services (EMS), the resident sustained a fall at the nursing home, the resident's history was unclear, and the resident did not normally ambulate independently. The report indicated EMS staff were told the resident received a bath and 15 minutes later, the facility staff found the resident lying in bed in the fetal position, crying for help, and the resident indicated she had fallen. The facility staff reported to EMS the resident had sustained a forehead contusion, a scalp laceration, and left leg edema. A facility post event Interdisciplinary Team (IDT) note, dated 6/28/23 at 11:36 p.m., indicated the type of event was an intercepted fall. CNA 4 was assisting the resident with a shower. CNA 4 turned to the sink to grab soap and the resident started to slip out of the shower chair. CNA 4 was assisting the resident back in the shower chair and the chair tipped backwards. The CNA grabbed the resident around the back and neck area to prevent the resident from falling hard on the floor. The resident was assisted upright in the shower chair and the shower was completed. The CNA assisted the resident into her wheelchair. While exiting the bathroom, the CNA hit the resident's knee on the door frame. The resident was assisted into bed and complained of knee pain. A head-to-toe assessment found a hematoma, skin tear, and pain to the knee. A hospital report, dated 7/7/23 at 3:33 p.m., indicated the final discharge diagnoses included a C1 fracture (a bone which begins at the base of your skull and often caused by trauma to the back of the head), Dens fracture type II (a break which occurred through a specific part of the second bone in the neck), Biffl Gr 4 Rt VA occlusion (illustrates the spectrum of blunt cerebrovascular injury), L1 compression fracture (bottom part of the thoracic spine, occurs from too much pressure on the vertebral body), Left medial (towards the middle) and lateral (away from the middle) femoral condyle (ball-shape located at the end of the femur, thigh bone) fractures and right 5th proximal phalanx(bone located tip of foot) and metatarsal (large bone in the foot) shaft fracture. A Certified Nursing Assistant (CNA) job description signed on 6/1/23 by CNA 4, indicated the essential job duties included, but were not limited to, assisting with resident with room moves, transfers, reports changes in condition or new concerns to the nurses, and other duties assigned by the nurse within the CNA scope of practice. During an interview, on 1/17/24 at 9:18 a.m., the Director of Nursing (DON) indicated, on 6/24/23 at 10:00 p.m., the nurse on duty contacted her and indicated the CNA gave Resident C a shower. When CNA 4 was assisting the resident to her bed, CNA 4 bumped the resident's knee on the door frame. The DON asked the nurse if she had concerns with the resident and the nurse stated the resident was in bed. The nurse went to assess the resident and noticed something on her hand and on her head. The DON asked the nurse if the resident was in pain and talked to CNA 4 asking if the resident fell . CNA 4 indicated the resident did not fall. The CNA was giving the resident a shower and the resident was sitting on the shower chair. CNA 4 turned to get the soap. When CNA 4 turned around, the resident was slipping out of the chair. The CNA hurried over to help the resident and repositioned her back into the shower chair. CNA 4 then took the resident out of the bathroom and bumped her knee on the door. The DON asked the nurse to do a head-to-toe assessment and the nurse found a small laceration on top of her head and a small skin tear on the resident's right hand. The left knee had some swelling, and the resident was complaining of neck pain. The DON told the nurse to notify the physician and send the resident to the hospital. The DON called the daughter multiple times until she was able to talk to her and explained to the daughter, she was going to further investigate the incident. The resident was at the hospital from 6/24/23 to 7/7/23. During an interview, on 1/17/24 at 10:16 a.m., the DON indicated the resident had a hematoma on the top of her head not on the forehead and the resident did not fall. The DON thought this was an isolated incident and would consider this an intercepted fall. The staff were not educated, only CNA 4. During an interview, on 1/17/24 at 11:28 a.m., the DON indicated what was reported to her was the resident did not fall. During an interview, on 1/17/24 at 11:59 a.m., LPN 5 indicated around 8:30 p.m., she was getting pudding out of the pantry and saw CNA 4 putting ice in a plastic trash bag for Resident C. CNA 4 had bumped the resident's knee on the door coming out of the bathroom. LPN 5 and CNA 4 went to the resident's room and found the resident asleep in the bed. The nurse pulled down the blanket, did not see anything, and left the room to give medications. LPN 5 returned to the room around 9:00 p.m. She did a head-to-toe assessment and asked the resident what happened. Resident C indicated she fell and was in pain. LPN 5 called the DON who instructed her to call the physician and send the resident to the hospital. During an interview, on 1/20/24 at 2:50 p.m., a family member of Resident C indicated there was confusion on what had happened to the resident. The facility contacted the family member, on 6/24/23 at 10:58 p.m., by voice mail. The facility was sending the resident out to the hospital due to complaints of neck pain. At first, the family member was told by the facility staff a CNA was giving the resident a shower and, on the way, out of the bathroom bumped the resident's knee on the door frame. The resident at the time of the transfer should have been assisted by more than one staff member. When the resident was assessed in the emergency room , the resident was found to have a contusion on the front of her head and one on the back of the head, a C1 fracture, a left distal femur fracture, and a potential right femoral neck fracture. The resident had not been the same cognitively since the fall. 46961 2. An Indiana Department of Health Intake Information report indicated Resident B had been dropped after a staff member improperly secured him to a lift. The clinical record for Resident B was reviewed on 1/16/24 at 11:23 a.m. The diagnoses included, but were not limited to, paroxysmal atrial fibrillation, type 2 diabetes mellitus with neuropathy, idiopathic autonomic neuropathy, and ataxic gait. An Admission Minimum Data Set (MDS) assessment, dated 7/28/23, indicated the resident did not experience cognitive impairment. Section GG (functional abilities and goals) indicated the resident required partial/moderate assistance with toilet transfers and the helper did less than half of the effort. A nursing progress note, dated 8/12/23 at 10:00 a.m., indicated the CNA 3 notified LPN 2 the resident was on the floor in his bathroom. The CNA indicated while transferring him on the sit-to-stand lift from the toilet, the resident fell off the stand-up lift. The resident was laying on his right side with the back of his head against the door frame and his feet on the stand-up lift. The resident was alert, confused, stated he felt sleepy, and his head hurt. The resident sustained a laceration of the right temple area and a skin tear to the right upper arm. The resident was transported to the emergency room . An interdisciplinary team review of falls and skin events, dated 8/12/23 at 10:00 a.m., indicated CNA 3 noted the resident was starting to slip through the sit-to-stand lift sling. The CNA went immediately behind the resident and braced the resident's fall with her body. The resident hit his head and right elbow on the sit-to-stand lift when the resident was being assisted down to the floor. A hospital emergency room note, dated 8/12/23 at 10:51 a.m., indicated Resident D was alert and pleasant, received routine anti-coagulants, and had sustained a 3.0 cm (centimeter) head laceration which required four sutures and a 5.0 cm right forearm laceration that required four sutures. A nursing progress note, dated 8/12/23 at 10:30 p.m., indicated the resident returned from the hospital. He had sutures to the right top of his head and a dressing to the right elbow. A nursing progress note, dated 8/13/23 at 5:32 a.m., indicated the resident was alert and oriented times 3, and denied pain and discomfort. The laceration to the right temple area had 9 sutures intact. The skin tear to the right forearm had 9 sutures intact. During an interview, on 1/18/24 at 11:54 a.m., the ADON (Assistant Director of Nursing) indicated the resident was assisted by one CNA and should have been assisted by 2. The resident did have a recommendation from therapy to transfer with a full body lift and not the sit-to-stand lift. He would refuse the full body lift and request the sit-to-stand lift. He had more syncopal episodes after his fall from the sit-to-stand lift. 3. During an observation, on 1/18/24 at 3:18 p.m., the Resident H was found sitting in a sling used for the mechanical lift. The resident was in the sling at the highest position with CNA 6 brushing her hair. During an interview, on 1/18/24 at 3:19 p.m., CNA 6 indicated she did not know the policy for using the facility mechanical lifts. CNA 6 was the resident's hospice CNA, and she did this all the time. LPN 8 indicated she asked if the staff could help, and CNA 6 indicated she did not need help. The clinical record for Resident H was reviewed on 1/16/24 at 3:13 p.m. The diagnoses included, but were not limited to, multiple sclerosis, anxiety disorder, depressive disorder, pain, and osteoporosis. A physician's order, dated 3/8/23, indicated to admit the resident to hospice. A facility document, titled Resident Information Sheet, dated 1/16/24, indicated the resident transferred using a Hoyer lift (mechanical lift). A Quarterly Minimum Data Set (MDS) assessment indicated the resident was dependent (helper did all the effort) to move from a lying position to a sitting position. A hospice interdisciplinary care plan, dated 2/21/22, indicated to transfer the resident with a Hoyer lift and assist of 2 from bed to chair only. A facility care plan, dated as revised on 11/26/23, indicated the resident was at risk for falls. The interventions included, but were not limited to, educate the resident, family, and caregivers about safety reminders and what to do if a fall occurred. The Hoyer pad was to be removed from under the resident while up in the Broda chair. A facility care plan, dated as revised on 11/26/23, indicated the resident had a self-care performance deficit. The interventions included, but were not limited to, communicate any changes in status to hospice services and nurse and to promote dignity by ensuring privacy. During an interview, on 1/18/24 at 3:20 p.m., LPN 8 indicated the CNA who used the mechanical lift alone was from hospice. The facility policy stated when you use a mechanical lift you needed to have 2 staff assisting with the transfer to be safe. During an interview, on 1/18/24 at 3:33 p.m., LPN 8 indicated the Director of Nursing (DON) had asked the hospice CNA if she was supposed to transfer a resident in a lift without help and CNA 6 indicated per the hospice policy she could. During an interview, on 1/18/24 at 3:47 p.m., the DON indicated she called the hospice supervisor, made hospice aware of the facility lift transfer, and if CNA 6 used a lift they should have assistance. A current policy, titled Using a Mechanical Lifting Machine, received from the ADON on 1/18/24 at 11:23 a.m., indicated .the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift .at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .mechanical lifts maybe used for tasks that require lifting a resident from the floor, transferring a resident from bed to chair, lateral transfers, lifting limbs, toileting or bathing or repositioning .types of lifts that may be available in the facility are .floor-based full body sling lifts, overhead full body sling lifts and sit to stand lifts A current policy, titled Fall Prevention and Management, dated as revised 6/2021 and received from the Clinical Support Nurse on 1/16/24 at 11:47 p.m., indicated .It is the policy of our community to ensure a safe environment with lease restrictive measurers while promoting the highest possible level of independence and quality of life .An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person - this is still considered a fall. The fall risk evaluation will be completed upon admission, quarterly, annually, and/or if a change in condition requiring completion of a new MDS occurs (Significant Change MDS) and when a fall occurs. An evaluation of all the causal factors leading to a resident fall should be completed .Head to toe evaluation by a licensed nurse is completed before the resident is moved .Emergency care will be provided to the resident following appropriate procedures if necessary. Emergency care will be provided to any resident who has head trauma unless the physician, resident, or family refuses such treatment. Documentation will include report/event report completion, the nurse's notes, and a fall investigation This Federal tag relates to Complaint IN00416352. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated and a physician's order for oxygen was obtained for 4 of 5 residents reviewed for respiratory care. (Residents 6, 41, 206 and 10). Findings include: 1. During an observation, on 1/11/24 at 1:53 p.m., the oxygen tubing and humidifier bottle for Resident 6 was not dated. The record for Resident 6 was reviewed on 1/16/24 at 10:23 a.m. Diagnoses included, but were not limited to, shortness of breath, history of acute respiratory failure with hypoxia, and unspecified congestive heart failure. A current order, with a start date of 11/2/23, indicated to change and date oxygen tubing and humidifier bottle in the evenings every Wednesday. During an interview, on 1/11/24 at 2:46 p.m., the Clinical Support Nurse indicated the oxygen tubing was not dated. 2. During an observation, on 1/11/24 at 2:38 p.m., Resident 41 was wearing oxygen, and the oxygen tubing was not dated. The record for Resident 41 was reviewed on 1/16/24 at 9:22 a.m. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia and anxiety disorder. There was no physician's order for the resident to wear oxygen or to change the oxygen tubing. During an interview, on 1/16/24 at 11:38 a.m., the DON (Director of Nursing) indicated there was not an order for the resident to wear oxygen. 3. During an observation, on 1/16/24 at 12:35 p.m., the oxygen tubing for Resident 206 was not dated. The record for Resident 206 was reviewed on 1/16/24 at 2:23 p.m. Diagnoses included, but were not limited to, sepsis, type 2 diabetes, and history of trans ischemic attack (TIA). A current order, with a start date of 1/9/24, indicated the resident wore oxygen at 2 liters per minute continuously. A current order, with a start date of 1/9/24, indicated to change the oxygen tubing weekly every Wednesday night. During an interview, on 1/11/24 at 2:48 p.m., the Clinical Support Nurse indicated the resident's oxygen tubing was not dated. 4. During an observation, on 1/11/24 at 2:38 p.m., Resident 10 was not wearing oxygen and the oxygen tubing and humidifier bottle was not dated. The record for Resident 10 was reviewed on 1/12/24 at 9:22 a.m. Diagnoses included, but were not limited to congestive heart failure, atrial fibrillation, and obstructive sleep apnea. A physician's order, dated 10/3/23, indicated oxygen at 2 liters per nasal cannula during the day as tolerated. A physician's order, dated 11/2/23, indicated to change the oxygen tubing twice a week. During an interview, on 1/11/24 at 1:32 p.m., LPN 2 indicated she did not know why the resident was not wearing his oxygen and the oxygen tubing was not dated. The oxygen tubing was changed by the night shift nurse and should be dated and initialed. A current policy, titled Oxygen Administration, dated as revised 10/2010 and received from the Clinical Support Nurse on 1/11/24 at 3:38 p.m., indicated .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the resident's care plan to assess of any special needs of the resident. Assemble the equipment and supplies as needed .Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. Tubing will be changed routinely and as needed/indicated 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the bed hold policy was provided to the resident and/or responsible party at the time of the hospital transfer for 1 of 1 resident reviewed for hospitalization . (Resident 54) Finding includes: The record for Resident 54 was reviewed on 1/18/24 at 2:34 p.m. Diagnoses included, but were not limited to, acute respiratory failure, congestive heart failure (CHF), atrial fibrillation, atherosclerotic heart disease of native coronary artery (a narrowing of the artery), hypertensive heart, and chronic kidney disease. A nursing progress note dated 11/16/23 at 10:41 a.m., Licensed Practical Nurse (LPN) 2 indicated the resident had an oxygen saturation of 65 to 78 percent on 4 liters of oxygen. The resident was tired with rapid breathing, shaking, and back pain. The Nurse Practitioner was called, and an order was received to send the resident to the hospital for evaluation. The resident's daughter who was also the resident's power of attorney was called and updated on the resident's condition and the order to transfer the resident to the hospital. There was no bed hold policy or transfer documentation in the record. During an interview, on 1/18/23 at 3:30 p.m., the ADON (Assistant Director of Nursing) indicated she was unable to find any documentation the bed hold policy was provided to the resident or resident representative when the resident was hospitalized . She indicated when a resident transferred to the hospital a bed hold policy and resident information should be given to the resident/resident representative. A current policy, titled Transfer or Discharge, Facility-Initiated, dated 10/2022 and received from the ADON on 1/18/24 at 5:25 p.m., indicated .residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, the resident's return is generally expected .notice of transfer is provided to the resident/representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g. in a monthly list of residents that includes all notice content requirements) .notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer .notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments .nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge 3.1-12(a)(25)(A) 3.1-12(a)(25)(B) 3.1-12(a)(26)

Based on observation, interview and record review, the facility failed to ensure a resident with compression gloves had a physician's order, a care plan and staff were educated on the use of the compression gloves for 1 of 2 residents reviewed for edema (Resident B), and failed to ensure an unlicensed staff member did not move a resident before reporting an incident and having the resident assessed for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: 1. During an observation, on 1/11/24 at 12:09 p.m., the Resident B was noted to have edema in his hands with compression gloves on both hands. During an observation, on 1/16/24 at 2:29 p.m., the resident did not have compression gloves on his hands. His bilateral hands are edematous. The clinical record for Resident B was reviewed on 1/16/24 at 11:23 a.m. The diagnoses included, but were not limited to, paroxysmal atrial fibrillation, type 2 diabetes mellitus with neuropathy, and idiopathic peripheral autonomic neuropathy. There was no physician's order for the compression gloves. A therapy progress note, dated 12/26/23, indicated the DON (Director of Nursing) and the NP (Nurse Practitioner) requested bilateral compression gloves for increased swelling in the resident's hands. The Occupational Therapy Assistant applied bilateral compression gloves with 3/4 finger length to allow for monitoring of the fingertips. The resident was educated on the purpose of the compression gloves. There was no documentation the staff was educated on the use of the compression gloves. A review of the Medication Administration and Treatment Records, for 12/2023 through 1/17/24, indicated the compression gloves were not documented in the records. There was no care plan for the use of compression gloves. During an interview, on 1/18/24 at 1:24 p.m., the ADON (Assistant Director of Nursing) indicated the resident had the compression gloves for edema in his hands. The compression gloves were not documented on the medication or treatment records. She was not aware of how the information for donning and doffing the compression gloves were shared with staff. 44598 2. A facility reportable incident report, dated 6/24/23 at 11:01 p.m., indicated Resident C experienced a fall while showering in her restroom (assisted). Following the fall/shower, the resident was noted with increased pain/swelling to left knee and complaint of neck pain during the nursing assessment. The resident was transported to the hospital for further evaluation and treatment. A written statement of events, untitled, dated 6/24/23 and not timed, by Certified Nurse Aide (CNA) 4 indicated CNA 4 was giving Resident C a shower between 7:00 to 7:30 p.m. The resident was placed on the shower chair. The CNA turned around and took the soap off the paper towel dispenser. When the CNA turned around, the resident was slipping out of the shower chair. The CNA tried to rush to her and ended up slipping causing the chair to come off its legs and tilt backwards. The resident hit her head. CNA 4 placed her hand on the back of the resident's neck and the other under her thigh. The CNA positioned the resident back on the shower chair and noticed the resident had blood on the top of her head. CNA 4 continued to give the resident a shower and rinsed the blood from the resident's head. She then transferred the resident into her wheelchair and pushed the resident to the side of her bed. The CNA bumped the resident's knee on the bathroom door frame. CNA 4 dressed the resident and transferred the resident into her bed. The resident was complaining of pain. The statement did not indicate the CNA notified the nurse before moving the resident or continuing the shower. A written statement of events, untitled, undated, and not timed, by LPN 5, indicated LPN 5 went into the pantry to get applesauce and found CNA 4 putting ice in a small trash bag. The CNA explained it was for Resident C and the CNA thought she bumped the resident's leg on the doorway. LPN 5 went into the resident's room and asked the resident what happened. The resident indicated she fell . The nurse asked the CNA if she fell , and the CNA stated she did not fall. When LPN 5 was completing her assessment, she noticed a small bag of ice on the resident's neck and the resident's forehead was bleeding with a small hematoma. The statement did not indicate how long after the shower the nurse was told the resident needed to be assessed. The clinical record for Resident C was reviewed on 1/16/24 at 10:06 a.m. The diagnoses included, but were not limited to, dementia, depression, and osteogenesis imperfecta (inherited disorder characterized by fragile bones). An admission Minimum Data Set (MDS) assessment, dated 3/23/23, indicated the resident was rarely/never understood. Her cognitive skills for decision making were severely impaired. She was dependent on staff for showering, bathing, and transfers. A care plan, initiated on 3/15/23, indicated the resident was at risk for falls. The interventions included, but were not limited to, alert the provider if a fall occurred, and initiate frequent neuro checks and bleeding evaluation per the facility protocol. A nursing progress note, dated 6/24/23 at 10:00 p.m., documented as a late entry, indicated the nurse was informed by CNA 4 she bumped the resident's knee on the bathroom door after completing a shower when exiting the bathroom. The CNA indicated Resident C needed ice. LPN 5 asked the resident if she was okay, and the resident stated she fell . LPN 5 noted the resident had pain to the left knee, a small skin tear to the right upper arm with a small amount of bleeding, and the left hand was discolored. The nurse did a head-to-toe assessment and noted the resident had a hematoma with a small laceration on the forehead. The progress notes did not indicate the time the head-to-toe assessment was completed. A hospital report, dated 6/25/23 at 12:27 a.m., indicated the resident arrived at the emergency department by the Emergency Medical Services (EMS), the resident sustained a fall at the nursing home, the resident's history was unclear, and the resident did not normally ambulate independently. A facility post event Interdisciplinary Team (IDT) note, dated 6/28/23 at 11:36 p.m., indicated the type of event was an intercepted fall. CNA 4 was assisting the resident with a shower. CNA 4 turned to the sink to grab soap and the resident started to slip out of the shower chair. CNA 4 was assisting the resident back in the shower chair and the chair tipped backwards. The CNA grabbed the resident around the back and neck area to prevent the resident from falling hard on the floor. The resident was assisted upright in the shower chair and the shower was completed. The CNA assisted the resident into her wheelchair. While exiting the bathroom, the CNA hit the resident's knee on the door frame. The resident was assisted into bed and complained of knee pain. A head-to-toe assessment found a hematoma, skin tear, and pain to the knee. The post fall note did not include how the time difference between the intercepted fall and the nursing head-to-toe assessment. There were no progress notes found in the resident's record to indicate the time the resident was sent out to the emergency department. A Certified Nursing Assistant (CNA) job description signed on 6/1/23 by CNA 4, indicated the essential job duties included, but were not limited to, assisting with resident with room moves, transfers, reports changes in condition or new concerns to the nurses, and other duties assigned by the nurse within the CNA scope of practice. A General Orientation Verification form, signed by CNA 4 on 6/6/23, indicated accidents were to be reported immediately to the supervisor. During an interview, on 1/17/24 at 9:18 a.m., the Director of Nursing (DON) indicated, on 6/24/23 at 10:00 p.m., the nurse on duty contacted her and indicated the CNA gave Resident C a shower. When CNA 4 was assisting the resident to her bed, CNA 4 bumped the resident's knee on the door frame. The DON asked the nurse if she had concerns with the resident and the nurse stated the resident was in bed. The nurse went to assess the resident and noticed something on her hand and on her head. The DON asked the nurse if the resident was in pain and talked to CNA 4 asking if the resident fell . CNA 4 indicated the resident did not fall. The CNA was giving the resident a shower and the resident was sitting on the shower chair. CNA 4 turned to get the soap. When CNA 4 turned around, the resident was slipping out of the chair. The CNA hurried over to help the resident and repositioned her back into the shower chair. CNA 4 then took the resident out of the bathroom and bumped her knee on the door. The DON asked the nurse to do a head-to-toe assessment and the nurse found a small laceration on top of her head and a small skin tear on the resident's right hand. The left knee had some swelling, and the resident was complaining of neck pain. The DON told the nurse to notify the physician and send the resident to the hospital. The DON called the daughter multiple times until she was able to talk to her and explained to the daughter, she was going to further investigate the incident. The resident was at the hospital from 6/24/23 to 7/7/23. During an interview, on 1/17/24 at 11:28 a.m., the DON indicated what was reported to her was the resident did not fall. During an interview, on 1/17/24 at 11:59 a.m., LPN 5 indicated around 8:30 p.m., she was getting pudding out of the pantry and saw CNA 4 putting ice in a plastic trash bag for Resident C. CNA 4 had bumped the resident's knee on the door coming out of the bathroom. LPN 5 and CNA 4 went to the resident's room and found the resident asleep in the bed. The nurse pulled down the blanket, did not see anything, and left the room to give medications. LPN 5 returned to the room around 9:00 p.m. She did a head-to-toe assessment and asked the resident what happened. Resident C indicated she fell and was in pain. LPN 5 called the DON who instructed her to call the physician and send the resident to the hospital. During an interview, on 1/20/24 at 2:50 p.m., a family member of Resident C indicated there was confusion on what had happened to the resident. The facility contacted the family member, on 6/24/23 at 10:58 p.m., by voice mail. The facility was sending the resident out to the hospital due to complaints of neck pain. At first, the family member was told by the facility staff a CNA was giving the resident a shower and, on the way, out of the bathroom bumped the resident's knee on the door frame. The resident at the time of the transfer should have been assisted by more than one staff member. When the resident was assessed in the emergency room , the resident was found to have a contusion on the front of her head and one on the back of the head, a C1 fracture, a left distal femur fracture, and a potential right femoral neck fracture. The resident had not been the same cognitively since the fall. A current policy, titled Using a Mechanical Lifting Machine, received from the ADON on 1/18/24 at 11:23 a.m., indicated .the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift .at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift A current policy, titled Fall Prevention and Management, dated as revised 6/2021 and received from the Clinical Support Nurse on 1/16/24 at 11:47 p.m., indicated .An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person .An evaluation of all the causal factors leading to a resident fall should be completed .Head to toe evaluation by a licensed nurse is completed before the resident is moved . Documentation will include report/event report completion, the nurse's notes, and a fall investigation This Federal tag relates to Complaint IN00416352. 3.1-37(a)

Based on interview and record review, the facility failed to notify the physician of a significant weight change and a 5 pound or more weight gain per the physician's orders for 2 of 3 residents reviewed for nutrition. (Resident D and 26) Findings include: 1. The record for Resident D was reviewed on 1/16/24 at 2:29 p.m. Diagnoses included, but were not limited to, muscle weakness, pain, anxiety disorder, and depression. A care plan indicated the resident was at nutrition risk. The interventions included, but were not limited to, monitor weights as ordered. The resident had the following weights: 1. On 10/22/23, the resident's weight was 109.0 pounds. 2. On 1/8/24, the resident's weight was 95.0 pounds. The resident had a 12.84% weight loss in 3 months. There was no documentation of the physician being notified of the significant weight loss. A nursing progress note, dated as a late entry on 1/16/24 at 1:00 p.m., indicated the Assistant Director of Nursing (ADON) discussed the resident's weight loss and no new orders were received. During an interview, on 1/16/24 at 4:35 p.m., the ADON indicated she notified the Nurse Practitioner (NP) and the Registered Dietician (RD) of the weight change. When residents have a significant weight loss, the resident needed to be re-weighed and the physician notified. The ADON indicated she spoke with the NP, on 1/9/24, and did not chart the conversation until 1/16/24 at 1:00 p.m. 2. The record for Resident 26 was reviewed on 1/17/24 at 10:25 a.m. Diagnoses included, but were not limited to, unspecified CHF (congestive heart failure), unspecified dementia, and hypertension. A current order, with a start date of 11/28/23, indicated to weigh the resident every day at the same time of day with the same scale. Notify the physician of a 3-pound weight gain in 24 hours or a 5-pound weight gain in 1 week. A weight log indicated the following: 1. On 11/29/23, the resident's weight was 140.3 pounds. 2. On 12/1/23, the resident's weight was 145.0 pounds. 3. On 12/1/23, the resident's weight was 146.8 pounds. There was a greater than 5-pound weight gain in less than 1 week from 11/29/23 to 12/1/23 and no notification to the provider was found in the resident's electronic chart. During an interview, on 1/17/24 at 3:35 p.m., the DON (Director of Nursing) indicated the provider signed the CHF log when they came in and when they notified the provider. During an interview, on 1/18/24 at 9:52 a.m., the ADON (Assistant Director of Nursing) indicated she could not find the CHF log for the time period the weight gain occurred. 44598 A current policy, titled Weight Assessment and Intervention, dated as revised 3/2022 and received from the DON on 1/17/24 at 3:41 p.m., indicated .Weights are recorded in each unit's weight record chart and in the individual's medical record. Any significant weight change since last weight assessment is retaken for confirmation. If the weight is verified, nursing will notify the dietitian. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe A current policy, titled Heart Failure-Clinical Protocol, dated as revised 11/2018 and received from the DON on 1/18/24 at 4:00 p.m., indicated .Daily weight monitoring may be ordered for residents with heart failure. Notification of significant weight changes to be followed per physician's order. 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to report a fall on the date of the fall, failed to document assessments and neurological checks after a fall and failed to transfer a resident using the correct transfer equipment after a fall for 1 of 3 residents reviewed for accidents. (Resident C) Resident C did not receive fall follow up monitoring for side effects related to a fall and was found to have a fracture to the right clavicle six (6) days after the fall. Finding includes: On 11/28/22 at 11:36 a.m., Resident C was observed in a Broda chair, slightly reclined, alone in her room. She appeared clean and dry, with her call light in reach. The resident did not respond to conversation. The record for Resident C was reviewed on 11/28/22 at 2:04 p.m. Diagnoses included, but were not limited to, unspecified dementia severe with anxiety, unspecified dementia severe with mood disturbance and age-related physical debility. The Minimum Data Set assessment, dated 06/10/22, indicated Resident C had a Brief Interview for Mental Status score of 01. (BIMS- screening tool used to assist with identifying a resident's current cognition, scores close to 0 indicate severe cognitive impact). An undated care plan indicated Resident C was as risk for falling due to impaired balance/mobility, vision, and cognition. An intervention indicated .Assist with mobility as needed. 3/18/21 Use Hoyer (full body mechanical lift) .as indicated .Status: Active (Current) There was no progress note related to the resident's fall on 10/29/22. There was no assessment of Resident C found in the record on the date of the fall on 10/29/22. There were no fall follow-up checks related to the fall on 10/29/22, 10/30/22 or 10/31/22. There was no initial neurological check for the fall, found in the record. There were no neurological rechecks related to the fall on 10/29/22 or the following 72 hours. The vital signs charted into the record on 10/29/22, was a blood pressure at 12:59 p.m., a heart rate at 12:15 p.m., a temperature at 12:59 p.m., an oxygen saturation at 12:59 p.m., and pain at 11:29 a.m. A progress note, dated 11/03/22 at 3:35 p.m., written by LPN 1 indicated .Writer was called down to resident's room by CNA staff. Writer went to room and upon assessment writer noticed skin discoloration and swelling to resident's right shoulder, right humerus, and right clavicle. Writer noticed resident facial grimacing occurring as writer was completing skin assessment .informed DON (Director of Nursing) .Hospice and NP (Nurse Practitioner) .family made aware .received new order for x-rays .to right shoulder, right humorous and right clavicle .V/S WNL (vital signs within normal limits) A progress note, dated 11/04/22 at 4:00 p.m., and entered on 11/28/22 at 11:32 a.m., titled IDT Review (Interdisciplinary Review), written by the Assistant Director of Nursing indicated .LATE ENTRY .Type of Event: Trauma to right shoulder on 11/3/22 .ROOT CAUSE: Trauma related to possible unwitnessed fall/advanced age and frailty A CNA work list, provided by the Director of Nursing on 11/29/22 at 12:05 p.m., indicated Resident C was to be transferred using a full body lift. A document, provided by the Director of Nursing on 11/29/22 at 9:59 a.m., titled Skilled Nursing Visit Note (name of company) Hospice indicated .Date of Visit 10/31/22 .Integumentary (skin) .Pallor .Warm .Dry .Loose/Lacks tone An untitled document, provided by the Director of Nursing on 11/28/22 at 4:30 p.m., indicated .Appt. Date/Time 11/03/22 11:46 a.m .female .is being seen today for reports of new onset right arm pain this am .Nurse was called to room when pt (patient) was moaning this morning during cares c/o (complaint of) her right arm hurting .On assessment nurse found scattered bruising to right shoulder and right upper back .The right shoulder was also noted to be swollen .No known falls or injuries have been reported .Will obtain XR (x-ray) of right humerus, right shoulder and right clavicle .Differentials include trauma related to unwitnessed fall, transfer trauma or spontaneous injury due to advance frailty The document was signed by the Nurse Practitioner 5 on 11/03/22 at 12:22 p.m. An x-ray result, provided by the Director of Nursing on 11/29/22 at 10:55 a.m., indicated Date of Service 11/03/22 .Conclusion: Fractured Clavicle A document, dated 11/04/22, provided by the Director of Nursing on 11/29/22 at 9:59 a.m., titled Event Report (Quality Assurance/Confidential) indicated Resident C fell on [DATE] at 7:30 a.m. There was no injury noted, neuro (Neurological) checks were within normal limits for the resident and range of motion was within normal limits. Resident C's vital signs were documented on the sheet. The physician and responsible party were notified on 11/03/22. A head-to-toe assessment was completed. The immediate intervention was the resident was moved to the nurse's station. The document had LPN 2's printed name on the signature line. The resident was unable to state if she was alright. The form was signed by the Director of Nursing on 11/04/22. A document, provided by the Director of Nursing on 11/28/22 at 4:30 p.m., titled Investigation Conclusion Statement indicated Interviewed Nurses/CNAS assigned to resident 11/3, 11/4 . (CNA 4) called 11/3/22 via phone with other members of management present. Asked .if she had noticed any changes .CNA stated she had not seen anything on the resident when initially asked. CNA was asked to confirm how resident was to be transferred and CNA stated she sometimes use the stand-lift, sometimes picks up resident or use (name of full body lift) by herself. CNA was asked if resident had anything on right side of her forehead and CNA stated, yes where she picked a mole off, I told the nurse. I informed CNA she needed to come in on 11/4/22 to discuss .regarding the resident. CNA agreed. CNA did not come in but placed a letter under DON (Director of Nursing) door On the same document it was noted LPN 2 was called on 11/04/22 and she was asked if there were any changes with Resident C .she was not aware of anything. Asked nurse did resident have a fall and nurse stated yes. She stated fall was on 10/29 and that CNA came to report that resident slid down from her chair. Nurse stated she completed assessment and vitals. No visual skin changes During a telephone interview, on 11/28/22 at 2:59 p.m., the family member of Resident C indicated he believed the last fall was when the resident injured her shoulder and the Director of Nursing had investigated the fall. He indicated the resident did get really agitated and it had been happening a lot lately. During an interview, on 11/28/22 at 3:40 p.m., LPN 1 indicated CNA 3 informed her Resident C had bruising. LPN 1 went to the resident's room and performed an assessment and found bruising at the right shoulder area. She notified the Director of Nursing. LPN 1 indicated the resident did not fall on her shift. The resident was still in bed when she was notified of the injury and went to assess her. During a telephone interview, on 11/28/22 at 3:49 p.m., CNA 4 indicated she was walking in the hall when she observed Resident C on the floor. She reported the resident on the floor to LPN 2. She did assist LPN 2 to get the resident off the floor and into the Broda chair (a wheelchair which tilts, reclined and had footrests). She did not observed LPN 2 to assess Resident C's vital signs. CNA 4 indicated LPN 2 asked her not to say anything and CNA 4 informed LPN 2 she did what she was supposed to do, she reported it to the nurse. During an interview, on 11/29/22 at 8:42 a.m., the Director of Nursing indicated the facility was not aware Resident C had fallen until they began interviewing staff. They have an event report filled out by LPN 2 and the interdisciplinary team did make a note of the fall. Upon investigation related to an injury to the right shoulder, they interviewed LPN 2, due to lack of documentation, to find out if Resident C had fallen. LPN 2 did inform the facility of the fall during the interview. The interview took place on 11/04/22, via telephone. The facility could not determine if the shoulder/clavicle fracture was a result of the fall. The hospice provider was in around 11/01/22 and assessed the resident. They did not find any bruising or signs of injury. On 11/03/22, CNA 3 reported to LPN 1 of bruising she found. LPN 2 requested the Director of Nursing observed the injury and the Director of Nursing noted the bruising. She did interview a CNA and found the CNA reported using a stand-up lift. The resident was to be transferred using a full body lift, not a stand-up lift. The improper transfer may have been a cause of the injury. The CNA had provided a written statement and then later verbally spoke of the fall. The CNA was asked to come into the facility and write a statement, instead she slid a written statement under the Director of Nursing's door. The Director of Nursing indicated LPN 2 should have written a progress note and notify the physician, as well as the family. During an interview, on 11/29/22 at 9:59 a.m., the Director of Nursing indicated the event report was not completed by LPN 2 until 11/04/22 and should have been completed on the day of the fall. The neurological checks and fall follow-up monitoring should have been completed for 72 hours after the fall. The family and physician were notified on 11/03/22; they should have been notified the day of the fall. Neurological checks were not completed because they were not aware of the fall until after the 72 hours had passed. The facility had an Interdisciplinary Team meeting around 11/06/22, but the documentation was not entered into the record until 11/28/22 because they were working on a plan of correction until 11/28/22. During a telephone interview, on 11/29/22 at 10:18 a.m., LPN 2 indicated Resident C had an un-witnessed fall on 10/29/22. The CNA came and informed her the resident fell . The resident was found on her back perpendicular to the Broda chair, and it looked like she slid out of the chair. She assessed the resident's vital signs, did the initial neurological check and then both her and the CNA transferred the resident into the Broda chair by lifting the resident. She lifted Resident C from under her arms and the CNA lifted the resident at the knees. She believed the resident was a fully body mechanical lift but there was no lift pad in the chair and the resident only weighed about 80 pounds. She did complete the initial neurological check on the resident but was unable to indicate where the documentation could be found and believed it was documented on paper. She did not notify the physician or family because she was busy, and the day got away from her. She did forget to document a progress note. Her responsibility was to do an assessment, do the neurological checks and to make a note. She did go to the facility, on 11/04/22, to complete the event report. The resident fell on a Saturday (10/29/22) and she did not report it. The first notification of the fall, to the facility, was on 11/04/22. A facility policy, titled FALL PREVENTION AND MANAGEMENT, dated as last reviewed June of 2021, and provided by the Director of Nursing on 11/28/22 at 4:30 p.m., indicated .Steps following a fall .Head to toe evaluation by a licensed nurse if completed before resident is moved .If the fall is unwitnessed neurological assessments will be conducted according to the neurological assessment policy .Documentation will include incident report/event report completion, the nurse's notes, and a fall investigation .Follow up resident assessment and documentation for seventy-two (72) hours will be completed in the medical record A facility policy, titled ABUSE PREVENTION PROGRAM, dated May 2017 and provided by the Director of Nursing on 11/29/22 at 12:05 p.m., indicated .Neglect .failure of the facility, its employees or service providers, to provide .services necessary to avoid physical harm, pain, mental anguish or emotional distress A facility policy, titled Neurological Assessment, dated as reviewed in May 2018 and provided by the Director of Nursing on 11/29/22 at 10:54 a.m., indicated .The purpose of this procedure is to provide guidelines for a neurological assessment .when following an unwitnessed fall .Neurological assessments are indicated .Following an unwitnessed fall .assessments will be documented on the neurological assessment tool .and completed as follows .Every 15 minutes for 60 minutes (1 hour) .Every 30 minutes for 60 minutes (1 hour) .Every 60 minutes for 120 minutes (2 hours) .Every shift for 72 hours This Federal tag relates to Complaint IN00395442. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to notify the physician and resident representative of an unwitnessed fall until six (6) day after the event had occurred for 1 of 3 residents reviewed for notification of change. (Resident C) Finding includes: The record for Resident C was reviewed on 11/28/22 at 2:04 p.m. Diagnoses included, but were not limited to, unspecified dementia severe with anxiety, unspecified dementia severe with mood disturbance and age-related physical debility. There was no documentation in the record to indicate the physician or resident representative had been notified of the fall on the day of the incident, 10/29/22. During an interview, on 11/29/22 at 8:42 a.m., the Director of Nursing indicated the facility was not aware Resident C had fallen until during an investigation related to an injury to the resident's right shoulder. They interviewed LPN 2 and found out Resident C had fallen. They had an event report filled out by LPN 2 and the interdisciplinary team did make a note of the fall. LPN 2 informed the facility of the fall during the interview, on 11/04/22, via telephone. LPN 2 should have written a progress note and notify the physician, as well as the family. During an interview, on 11/29/22 at 9:59 a.m., the Director of Nursing indicated the event report was not completed by LPN 2, until 11/04/22, and it should have been completed on the day of the fall. The family and physician were notified on 11/03/22; they should have been notified the day of the fall. During a telephone interview, on 11/29/22 at 10:18 a.m., LPN 2 indicated Resident C had an un-witnessed fall on 10/29/22. She indicated she did not notify the physician or family because she was busy, and the day got away from her. She forgot to document a progress note. Her responsibility was to do an assessment, do the neurological checks and to make a note. She did go to the facility on [DATE] to complete the event report. The resident fell on a Saturday (10/29/22) and she did not report it. The first notification of the fall, to the facility, was on 11/04/22. A facility policy, titled Change in a Resident's Condition or Status, dated as revised in February 2021 and provided by the Director of Nursing on 11/29/22 at 10:54 a.m., indicated .The nurse will notify the resident's attending physician or physician on all when there has been a(an) .accident or incident involving the resident This Federal tag relates to Complaint IN00395442. 3.1-5(a)(1)

Based on observation, interview and record review, the facility failed to ensure residents at risk for development of pressure ulcers received the necessary care, treatment and services, consistent with professional standards of practice, to prevent worsening of a pressure ulcer and promote healing for 1 of 3 residents reviewed for pressure ulcers. (Resident 73) Resident 73 had developed a pressure ulcer at the facility and wound was discovered as a stage 2. Finding includes: During the initial tour of the facility, on 10/27/2022 at 1:00 p.m., Resident 73 was observed sitting, in a reclining Broda chair, in her room. A pressure reducing cushion was in the seat of the chair and a low air mattress was on the resident's empty bed. The resident did not respond to her name being called or a knock on the room door. The CNA (Certified Nursing Assistant) care sheet, on this date, was obtained from the unit nurse which indicated the resident was a mechanical lift transfer and required turning and repositioning every 2 hours. The record for Resident 73 was reviewed on 10/28/2022 at 3:32 p.m. Diagnosis included, but were not limited to, dementia, hemiplegia following a cerebral infarction (stroke) affecting the left side, age related physical debility, sacral pressure ulcer stage 3, abnormality of gait and contracture of the left hand. Admission physician's orders, included, but were not limited to, Weekly Visual Skin Assessment - Complete a Head-to-toe Visual Skin Assessment with the resident shower 1 (time) every Week - Note Intact Skin IF THE RESIDENT HAS ANY NOTED OPEN AREAS, SKIN BREAKDOWN, BRUISES, OR IF SKIN INTEGRITY IS COMPROMISED . The resident's skin care regime, at the time of admission, indicated a physician's order to Cleanse perineum with soap et (and) water. Rinse. Dry et apply calazime (a skin protectant paste) bid (twice a day) et prn (when necessary) after incont (incontinent) episodes. A Nursing Evaluation, dated 06/17/2022, indicated the condition of the resident's skin at the genitals, perineal and buttock areas had some redness and described the area as follows: Type - rash Body part - groin/pubic area Location - back Appearance - healing Odor - none Drainage - none Drainage appearance - clear Length - 2 cm (centimeters) Width - 1 cm Depth - 0.1 cm Shower sheets completed on the date of discovery of the pressure ulcer, and the week following, titled Care giver Body Check Worksheet, indicated the following: On 06/17/2022, to the question of any rashes?, the staff completing the worksheet answered yes, with the location being the butt. On 06/21/2022, to the question of Any open lesions, cuts, lacerations, or skin tears?, staff completing the worksheet answered yes, and to the question of Any open ulcers?, staff completing the worksheet answered no. The first full description of the pressure ulcer, dated 06/24/2022, 7 days following the discovery of the initial stage 2 pressure ulcer, described the wound as a stage 3 with tissue type as Pale Pink Non-granulating = 10% and Slough White Fibrinous = 90%. The current plan and comments included, .New area noted to buttocks . The pressure ulcer measured, on this date, 2 cm by 1.5 cm with a depth of 0.2 cm and a scant amount of serosanguinous drainage. The first physician's order related to the pressure ulcer was dated 06/22/2022 and indicated to Cleanse area to sacrum with normal saline, pat dry, apply skin prep to periwound, apply saline moistened hydrofera blue (a bacteriostatic foam dressing), ring out excess saline and to cover with bordered foam . On 11/02/2022 at 11:31 a.m., the pressure ulcer was observed. Resident 73 was lying in bed and turned to her left side. When the resident's brief was removed by the wound nurse, a stage 3 pressure ulcer was seen at the sacral/coccyx area. The wound, when measured at this time by the wound nurse, measured 1 cm in length with a width of 0.5 cm and a depth of 0.3 cm. The wound edges were clean and well approximated with dark brown to black tissue covered the wound base. No drainage was noted at the time of the observation. During an interview, on 10/28/2022 at 11:00 a.m., the wound nurse reviewed the images of the pressure ulcer and indicated Resident 73 had developed the pressure ulcer at the facility and wound was discovered as a stage 2 on 06/17/2022. The resident was totally dependent on staff for activities of daily living and was incontinent of bowel and bladder. At the time of discovery, the wound measured to be 2 cm (centimeter) in length by 1 cm in width and 0.1 cm in depth. A current facility policy, titled Pressure Ulcer Prevention and Skin Management, dated as last revised June 2021 and received from the Assistant Director of Nursing on 11/01/2022 at 12:25 p.m., indicated .Program Overview - Each health center is to implement a pressure ulcer prevention and management program. The program shall emphasize prevention of pressure ulcers. All pressure ulcers will be managed to promote optimal healing 3.1-40(a)(2)

Based on interview and record review, the facility failed to complete, encode and transmit a Discharge Minimum Data Set (MDS) assessment for 10 of 11 residents reviewed for resident assessment. (Resident 1, 2, 3, 4, 5, 6, 7, 8, 11 and 16) Findings include: 1. A review of the MDS Discharge Assessment-14 day for Resident 1 indicated a discharge date of [DATE], was created on 10/28/22, and had not been submitted at the time of the survey. A review of the medical record indicated the Discharge MDS for Resident 1 had not been submitted in accordance with the RAI manual. 2. A review of the MDS Discharge Assessment-14 day for Resident 2 indicated a discharge date of [DATE], was created on 10/28/22, and had not been submitted at the time of the survey. A review of the medical record indicated the Discharge MDS for Resident 2 had not been submitted in accordance with the RAI manual. 3. A review of the MDS Discharge Assessment-14 day for Resident 3 indicated a discharge date of [DATE], and submission date of 10/28/22. A review of the medical record indicated the Discharge MDS for Resident 3 had not been submitted in accordance with the RAI manual. 4. A review of the MDS Discharge Assessment-14 day for Resident 4 indicated a discharge date of [DATE], and submission date of 10/31/22. A review of the medical record indicated the Discharge MDS for Resident 4 had not been submitted in accordance with the RAI manual. 5. A review of the MDS Discharge Assessment -14 day for Resident 5 indicated a discharge date of [DATE], and submission date of 10/28/22. A review of the medical record indicated the Discharge MDS for Resident 5 had not been submitted in accordance with the RAI manual. 6. A review of the MDS Discharge Assessment-14 day for Resident 6 indicated a discharge date of [DATE], was created on 10/28/22, and had not been submitted at the time of the survey. A review of the medical record indicated the Discharge MDS for Resident 6 had not been submitted in accordance with the RAI manual. 7. A review of the MDS Discharge Assessment-14 day for Resident 7 indicated a discharge date of [DATE], and submission date of 10/28/22. A review of the medical record indicated the Discharge MDS for Resident 7 had not been submitted in accordance with the RAI manual. 8. A review of the MDS Discharge Assessment -14 day for Resident 8 indicated a discharge date of [DATE], and submission date of 10/20/22. A review of the medical record indicated the Discharge MDS for Resident 8 had not been submitted in accordance with the RAI manual. 9. A review of the MDS Discharge Assessment-14 day for Resident 11 indicated a discharge date of [DATE], and the discharge had not been submitted at the time of the survey. A review of the medical record indicated the MDS for Resident 11 had not been completed or submitted in accordance with the RAI manual. 10. A review of the MDS Discharge Assessment-14 day for Resident 16 indicated an ARD with a date of 6/24/22, was created on 10/31/22, and had not been submitted at the time of the survey. A review of the medical record indicated the MDS for Resident 16 had not been completed or submitted in accordance with the RAI manual. During an interview, on 11/1/22 at 9:58 a.m., the MDS Coordinator indicated the 14-day discharge assessment had not been completed or submitted on time. The facility got behind on submission due to illness within the department. During an interview, on 11/1/22 at 2:09 p.m., the Director of Nursing (DON) indicated the facility would refer to the RAI for the timing of submissions. During an interview, on 11/01/22 at 2:46 p.m., the Administrator indicated he was not aware of any recent concerns in the last few months regarding late MDS submissions. The facility had not completed audits or reviewed MDS submission in the QAPI program. During an interview, on 11/1/22 at 4:33 p.m., the DON indicated the Corporate MDS Coordinator had identified a concern regarding late submission of the MDS. During an interview, on 11/1/22 at 3:33 p.m., the Administrator indicated if the resident's discharges were submitted late, it could affect the facility census and cause an error on the Payroll Based Journal (PBJ) report. A current facility policy, titled MDS completion and submission Timeframes, dated as revised 7/17, indicated the facility would conduct and submit resident assessment in accordance with current federal and state submission timeframes. 3.1-31(b)

Based on observation, interview and record review, the facility failed to ensure staff followed fall interventions and completed a root cause analysis for 4 of 4 residents reviewed for accidents. (Resident 17, 32, 35 and 69 ) Findings include: 1. During an observation, on 10/21/22 at 9:31 a.m., Resident 17 was found seated, in her Broda chair, leaning over to her left side of the arm rest. During an observation, on 10/28/22 at 10:34 a.m., Resident 17 was observed lying, in bed, facing the wall covered with a blanket. At the foot end of the blanket, the call light was attached to her blanket. The fall mat was standing up on its side next to the wall away from Resident 17. The record for Resident 32 was reviewed on 10/31/22 at 10:30 a.m. Diagnoses included, but were not limited to, dementia and a history of falls. An Event report, dated 8/29/22 at 12:20 p.m., indicated Resident 17 had an unwitnessed fall and was found on the floor in front of the closet in her room. Immediate interventions were implemented to provide 30-minute checks for days. A Unit Manager Event Review report, dated 8/29/22, indicated Resident 17 was confused and had a fall. The report indicated the root cause for the fall was staff performance and a new intervention was for staff education to be provided. An Event report, dated 10/15/22 at 7:00 p.m., indicated Resident 17 had an unwitnessed fall and was found on the floor. Immediate interventions were implemented to provide one to one supervision, promptly lay down after meals and frequent checks. A Unit Manager Event Review report, dated 10/15/22, indicated Resident 17 was confused and had a fall. The report lacked indication a root cause was completed, or a new intervention was placed after review. A fall risk assessment was completed, on 10/17/22, and indicated Resident 17 was a high risk for falls. A care plan, with a print date of 11/3/22, indicated Resident 17 had a risk for falls related to impaired balance, impaired cognition and a history of falling. The care plan indicated: a. Not to leave the resident alone in her room when up in her wheelchair. b. Assist with mobility as needed. c. Assist to walk as desired. d. Obtain a soft touch call light. e. Keep the bed in a low position. f. Do not leave her alone in the bathroom. g. Anticipate needs as indicated and give frequent cues. h. Identify specific interventions to aid in prevention of falls. i. Place the call system and most frequently used items within reach of the resident. j. Bed against the wall and a fall mat beside the bed. k. Check and change each round and toilet as needed. l. Promptly lay down after meals. During an interview, with Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 11/3/22 at 9:30 a.m., the DON indicated she was not sure if a call light to the end of a blanket would work for alerting the staff if Resident 17 was to attempt to get out of bed. The fall mat should be placed next to Resident 17 while she was in bed and staff would provide checks throughout the day to ensure she was safe. 2. During an observation, on 11/1/22 at 10:19 a.m., Resident 32 was observed, in the hallway, directly in front of the nursing station. A hospice nurse was observed standing in front, to the left side of the nursing station, just past the wall and out of view of the resident. No staff were observed in either hallway which had direct view of the resident. Resident 32 was in her wheelchair, her wheels were unlocked when she attempted to stand and hit her head on the sling attachment bar of the Hoyer lift. The stabilizing leg was stuck between the wheels. She sat back down in her wheelchair and continued to push the wheel but was unable to move the chair free. Resident 35 stood back up and attempted to step away unsteadily from the wheelchair. Resident 35 was prompted to sit down and staff were prompted to intervene and assist the resident. The record for Resident 32 was reviewed on 11/1/22 at 10:30 a.m. Diagnoses included, but were not limited to, dementia, aphasia (a loss of ability to understand or express speech). A Quarterly Minimum Data Set (MDS) assessment, dated 10/17/22, indicated Resident 32 had a severe cognitive impairment with inattention, disorganized thinking, had two falls and impaired vision. She required extensive physical assistance of one staff for assistance with transfers and locomotion on the unit. A care plan indicated Resident 32 was at risk for falls due to impaired balance, impaired cognition, history of falling, and impaired vision. The care plan indicated: a. Provide cues and supervision while ambulating. b. Obtain a soft touch call light. c. Encourage activities in the afternoon. d. Provide Resident 32 orientation to the room and call system. e. Use fall mat at bedside. f. Keep bed in low position. g. Bed against the wall. h. Dycem in recliner. i. Offer to toilet after meals. A Unit Manager Event Review report, dated 5/20/22, indicated Resident 32 had a fall. She was found on the floor by housekeeping staff playing with hats. The root cause determined Resident 32 had a diagnosis of dementia and was reaching, forgets limitation and had poor safety judgement. A wheelchair evaluation was added as an intervention. A nurse progress note, dated 6/6/22 at 1:45 p.m., indicated Resident 32 had an unwitnessed fall and was found in her room, on the floor. Interventions added for Resident 32 was for the staff to place the call light in reach. A nurse progress note, dated 7/3/22 at 7:45 a.m., indicated Resident 32 had an unwitnessed fall and was found down, on the floor, in the hallway. Interventions added for Resident 32 was for the staff to place the call light in reach. An Event report, dated 8/25/22 at 2:05 p.m., indicated Resident 32 was found on the floor, in her room, asleep with her blanket over her. A Unit Manager Event Review report, dated 8/25/22, indicated Resident 32 had a fall. A new intervention was added to offer Resident 35 a coca cola and to assist to toilet at bedtime and early morning. The review lacked indication a root cause was completed. A post fall follow up progress note, dated 10/29/22, indicated Resident 32 had a fall in the second-floor hallway, on 10/28/22 at 6:00 p.m., when she was found lying on her left side in front of her wheelchair yelling out for help. The progress notes further indicated 15-minute checks was initiated. Resident 32's care profile, undated, indicated she was a fall risk, put the bed in the low position and against the wall, fall mat at bedside, a soft touch call light, wheelchair within reach of the bed, dycem to recliner and a nightlight in her room. The care profile lacked indication staff were to offer a coca cola, provide cues and supervision while ambulating. A root cause analysis was requested and not provided for the falls on 6/6/22, 7/3/22 and 8/25/22. During an interview, on 11/1/22 at 10: 22 a.m., Nursing Assistant (NA) indicated Resident 32 had her wheelchair stuck in the Hoyer lift leg and could have fallen if staff did not intervene. During an interview, on 11/1/22 at 10:25 a.m., the Assistant Director of Nursing (ADON) indicated Resident 32 was at risk for falls and had fallen in the past. Resident 32 was able to ambulate at times but used the handrails for support. Resident 32 could have fallen and sustained an injury when she got her wheelchair stuck in the Hoyer lift and attempted to free it on her own. The Hoyer lift should have been stored in the appropriate resident's bathroom instead of in the hallway. During an interview, on 11/3/22 at 9:30 a.m., the DON and ADON indicated Resident 32 was a fall risk and required assistance from staff for transfers. The staff should keep the call light within reach for Resident 32 to use and staff should be providing checks throughout the day for safety. 3. During an observation, on 10/27/22 at 12:42 p.m., Resident 35 was found sitting up with the head of the bed up. She was observed, above her left eye, to have a one and half inch bruise and down past her left cheek was red and bruised. She had an abrasion on the bridge of her nose. Above her left eye were five steri-strips, soaked through with blood, which covered a wound. During an observation, on 10/28/22 at 9:36 a.m., Resident 35 was heard yelling out please, please, help, help. Upon entering Resident 35's room, she was observed seated in her reclining chair, in her room, with the feet elevated. The call light was hanging over the bedrail of her bed more than 9 feet away from the resident. No staff were observed near her room. During an observation, on 10/28/22 at 10:46 a.m., Resident 35 was found lying in her bed with her eyes closed. Her call light was found lying on the floor near the top right wheel of the exit side of the bed. The bed was in the low position. During an observation, on 11/1/22 at 9:45 a.m., Resident 35 was heard calling out help, help me and was found in her room seated in the reclining chair with the footrest elevated. The over the bed table was positioned over her lower legs. She had both her legs over the left side of her footrest. Her call light was tucked inside the cushion on the left side of the reclining chair beneath her left hip. Resident 35 indicated she was tired and wanted to go to bed. The record for Resident 35 was reviewed on 10/31/22 at 9:30 a.m. Diagnoses included, but were not limited to, dementia and repeated falls. A Quarterly Minimum Data Set (MDS) assessment, dated 8/4/22, indicated Resident 35 had a severe cognitive impairment and demonstrated no behaviors. She required extensive physical assistance of one staff person to assist with bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. She had falls with injuries and used a wheelchair for locomotion. A care plan indicated Resident 35 was a fall risk and indicated to: a. Apply anti-rollbacks to wheelchair. b. Keep bed against the wall c. Place Fall mat at bedside. d. On 12/4/21, staff were to keep her wheelchair within reach when she was in bed. e. On 11/26/21, staff were to obtain a soft touch call light. f On 11/28/21, staff were to offer and assist resident to lay down after meals. g. On 11/27/21, staff were to assist her to wear hipsters to aide in prevention of hip injury and apply in a.m. h. Place the call system and most frequently used items within resident's reach. i. Provide resident orientation to room and call system. j. On 1/17/21, staff were to offer and assist with toileting a minimum of every two hours while awake. k. On 12/10/21, staff were to encourage and assist resident to sit in her recliner after dinner. l. On 12/13/21, therapy was to provide dycem for wheelchair. m. On 11/29/21, staff were to ensure bed controls are secured in appropriate and safe place while resident was in bed. n. On 12/15/21, staff were to supervise resident during meals. o. On 10/1/22, staff were to offer, Resident 35, 15-minute checks until management review and allow to sleep as long as possible before meals. Resident 35's care profile, undated, indicated she was a fall risk and needed antiroll backs to the wheelchair, bed in the lowest position, fall mat at bedside, a soft touch call light, wheelchair within reach of the bed, and dycem to the wheelchair. Staff were to place the call light and items used frequently within reach, encourage activities, supervise during meals, lay down after meals, offer early bedtime, offer to get up if awake and not to leave the resident alone in the bathroom. A review of the facility's falls, in the past 6 months, indicated Resident 35 had 11 falls from May to October 2022. A Resident Incident Assessment indicated Resident 35 had an unwitnessed fall on 5/25/22 at 4:00 p.m., when she was found sitting, in her bathroom, on the floor. She sustained skin tears to her left knee and elbow. Post fall interventions included to have the resident, in her wheelchair, at the nurse's station and to have a call light in reach when in her room. A Resident Incident Assessment indicated Resident 35 had an unwitnessed fall on 6/2/22 at 10:10 a.m., when she was found lying on the left side, on her floor, near her bed. Post fall, the facility added interventions to place her bed against the wall and the aide was too standby when the resident was toileting. A Resident Incident Assessment indicated Resident 35 had a fall on 7/16/22 at 10:00 a.m., at the nurse's station. The resident pushed against the wall, tilted her wheelchair and fell on her left side. She hit the outer left side of her eye and sustained a skin tear to her left knee. Post fall 30-minute checks were added to Resident 35 interventions. A Resident Incident Assessment indicated Resident 35 had a fall, in the hallway, on 8/4/22 at 2:30 p.m. The resident was incontinent of loose stool at the time of fall. She sustained a 1.0 cm laceration to her left forehead and her left knee was skinned. Post fall additional interventions of 15-minute checks for 15 days were added. She was also sent to the emergency room for evaluation. A Unit Manager Event Review report, dated 8/4/22, indicated Resident 35 had a fall with injury. The report indicated the root cause was related to toileting, weakness, poor safety judgement and wheelchair not dumped. The report indicated a new intervention was initiated by the facility for staff to offer to lie down after activities and provide 15 minute checks. An occupational therapy (OT) initial assessment, dated 7/28/22, indicated they had completed a wheelchair evaluation due to the history of frequent falls. The assessment indicated Resident 35 was a fall risk and had precautions for falls, cognitive impairment and she was hard of hearing. OT indicated the resident to have 24/7 nursing assistance. An OT daily treatment note, dated 8/10/22, indicated Resident 35 had an unwitnessed fall on 8/2/22, when she attempted to stand from her wheelchair. Her leg rests were not in place at the time of the fall. Staff were educated on the importance of leg rest for fall prevention. A Resident Incident Assessment indicated Resident 35 had a fall, on 8/23/22 at 4:00 p.m., where she was found in her room on floor. Post fall additional interventions of frequent checks, with nurse, and spoke to son were added. A Unit Manager Event Review report, dated 8/23/22, indicated Resident 35 had a fall. The report indicated a lack of a root cause. A new intervention for staff to encourage short sleep cycles (naps) during the daytime hours. A Resident Incident Assessment indicated Resident 35 had a fall, on 9/1/22 at 8:00 p.m. She was found by a Certified Nursing Assistant (CNA) on the floor in her room. Resident 35 had sustained an abrasion to her left elbow. Post fall interventions added for Resident 35 were one-to-one supervision, frequent checks, bed in low position with a fall mat in place, call light in reach and toilet every two hours. A Unit Manager Event Review report, dated 9/1/22, indicated Resident 35 had a fall with a head injury. The report indicated the root cause was related to staff performance. The report lacked a new intervention was initiated by the facility. A Resident Incident Assessment indicated the resident had a witnessed fall in her bathroom, on 9/16/22 at 7:30 a.m., when she fell off the toilet after she had bent down to pull up her pants. She sustained a 2.5 cm (centimeter) by 5 cm laceration to the left side of her forehead and a skin tear to the bridge of her nose. the resident had steri-strips and dressing applied to her injuries. Post fall interventions added for Resident 35 were one-to-one supervision, frequent checks, bed in low position with a fall mat in place, call light in reach and toilet every two hours. The assessment lacked indication Resident 35 had been evaluated at the emergency room after she sustained a head injury. A Unit Manager Event Review report, dated 9/16/22, indicated Resident 35 had a fall with injury. The report indicated the root cause was related to toileting, balance and staff performance. A new intervention of staff education was indicated for Resident 35. A Resident Incident Assessment indicated Resident 35 had a fall, on 10/1/22 at 11:15 a.m., in a room when she had propelled herself and flipped the wheelchair over on top of herself. Post fall, the facility placed an intervention to take resident to bed per her request. A Unit Manager Event Review report, dated 10/1/22, indicated Resident 35 had a fall with injury. The report lacked indication of a root cause. A Resident Incident Assessment indicated Resident 35 had a fall at the nurse's station, on 10/27/22 at 7:00 a.m. Resident 35 was up in her wheelchair when she attempted to get out of the chair and landed on her face. She sustained a 0.1 cm by 0.1 cm by 0.1 cm laceration to her forehead. The facility added the intervention for staff to clean wound and apply steri -strips. A root cause analysis was requested and not provided for the fall on 10/27/22. 4. During an observation, on 10/27/22 at 2:05 p.m., Resident 69 had significant amount of bruising to her right side of her face which covered from her jaw line up past her forehead. A large black colored bump was just above her right eyebrow. She had her right hand up to her forehead rubbing the black colored bump. During an observation, on 10/28/22 from 9:25 a.m., to 9:53 a.m., Resident 69 was seated in a reclining Broda chair at the nursing station, rubbing her forehead and eye. She had facial grimacing while she was rubbing her head. No staff were observed at the nurse's station until 9:53 a.m., when an aide came up to take Resident 69 back to her room. The record for Resident 69 was reviewed on 10/31/22 at 9:30 a.m. Diagnoses included, but were not limited to, dementia, subdural hemorrhage, muscle weakness, macular degeneration and repeated falls. Resident 69's care profile, undated, indicated she was a fall risk and staff were to keep the bed in the lowest position, use a fall mat at bedside, place in recliner when in room and the resident was not to be in her wheelchair alone when she was in her room. The staff were to use Dycem to the wheelchair when she was in her room alone, offer activities, put the bed next to the wall and use a soft touch call light. A Physical Therapy (PT) Discharge Summary, dated 3/30/22, indicated Resident 69 had dementia with memory impairment and was a fall risk. She had a right arm fracture on 2/24/22. A physician progress note, dated 9/9/22 at 9:49 a.m., indicated Resident 69 was hospitalized from 5/23/22 to 5/28/22, for an unwitnessed fall resulting in right temporal and tentorial subdural hematomas. She sustained a left maxillary fracture and a left periorbital hematoma. Resident 69 had fractures of the first and second vertebral body and a right first rib fracture. An Event Report, dated 10/18/22, indicated Resident 69 had an unwitnessed fall with a right side hematoma. The resident was found face down, on the floor of the room, in front of the Broda chair. The root cause indicated the resident scooted forward. Interventions added to Resident 39 was for staff to provide 15-minute checks for three days. A Unit Manager Event Review report, dated 10/19/22, indicated Resident 69 had a fall with injuries. The report indicated the root cause was related to decreased safety awareness. The report lacked indication new interventions were added after the manager review. An Event Report, dated 10/19/22 at 8:10 a.m., indicated Resident 69 had an unwitnessed fall and was found lying on her right side on the floor near her chair. She had a 4 cm by 4 cm hematoma to her right side of head and bruising to her forehead and under her right eye. Interventions prior to the fall included to assess for pain, use specialized call light and keep the call light within reach. Immediate interventions implemented were for the staff to get the resident up right before meals and neuro checks were initiated. A Unit Manager Event Review report, dated 10/19/22, indicated Resident 69 had a fall with injuries. The report indicated the root cause was related to decreased safety awareness. The report lacked indication new interventions were added after the manager review. An Occupational Therapy evaluation, dated 11/1/22, indicated Resident 69 was a fall risk, had an overall decrease in overall strength and functional activity tolerance. She received daily assistance with all self-care task and functional mobility. During an interview, on 11/3/22 at 10:45 a.m., the ADON indicated the Administrator was the person at the facility to report incidents related to falls and fractures. The incident investigation report lacked indications Resident 69 sustained fractures after her fall on May 23, 2022. Resident 69 was a fall risk and sustained a hematoma on 10/19/22. During an interview, on 11/3/22 at 10:45 a.m., the DON indicated her expectation for staff would be to follow the residents care plan and provide the supervision and assistance as directed for each resident. During an interview, on 11/4/22 at 4:30 p.m., the Administrator indicated the facility had identified resident falls as a concern and was currently reviewed in the quality assurance and performance improvement (QAPI) meetings. A review of the falls in the last six months for second floor report, undated, indicated a total of 87 falls had occurred from 4/2/22 to 10/27/22. A current facility policy, titled Falls and Fall Risk, Managing, dated 3/18, indicated staff were to identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. 3.1-45(a)(2)

Based on observation, interview and record review the facility failed to ensure a pressure ulcer was identified prior to being unstageable, failed to accurately and timely assess the pressure ulcer to prevent the decline in the pressure with increased depth and tunneling and failed to infection control standards during a dressing change for 1of 2 residents reviewed for pressure ulcers. (Resident 46) Finding includes: The record for Resident 46 was reviewed on 7/17/19 at 11:17 a.m. [DIAGNOSES REDACTED]. A clinical note, dated 6/18/19, indicated, .Wound to coccyx assessed by this author and hospice. Noted to be unstageable The Resident's record did not include a wound assessment for 6/18/19. A physician's orders [REDACTED]. A care plan dated 6/21/19 indicated a pressure ulcer to the coccyx with interventions that included, but were not limited to, check and measure weekly and notify the physician of lack of healing/worsening as indicated. A clinical note, dated 7/2/19, indicated, .Sacral wound noted to have foul odor, necrosis (tissue death) noted. Hospice nurse notified and new order for crushed [MEDICATION NAME] (an antibiotic used to decrease odor in wounds) mixed with medi honey and cover The Resident's record did not include a wound assessment for 7/2/19. A progress note from (name of wound care company), dated 7/3/19, indicated, .The wound is currently classified as a unstageable/unclassified .pressure ulcer and is located on the sacrum. The wound measures 4 cm length x 4 cm width x 0 cm depth During a dressing change observation on 7/16/19 at 12:08 p.m., with the first floor unit manager LPN 2, she gathered the supplies and placed them on the resident's night stand. She donned clean gloves and began mixing the [MEDICATION NAME] and [MEDICATION NAME] together in a medication cup. She then removed the old dressing from the resident's coccyx. The old dressing was foul smelling odor and had purulent drainage on the dressing. She then discarded it into the trash. She removed her soiled gloves and donned a new pair of gloves without performing hand hygiene. She then cleansed the wound, removed her gloves and donned new gloves without performing hand hygiene. She then applied the [MEDICATION NAME] with a disposable spoon which she was able to insert the head of the spoon into the wound bed. She applied a dressing which did not fit so she removed it and applied a new dressing. The Resident's record did not include a wound assessment for 7/16/19. A clinical note, dated 7/17/19, indicated, .Late entry .effective date 7/16/19 .Resident wound care performed as per MD order .No significant changes noted at this time A clinical note, dated 7/18/19, indicated, .Wound rounds completed. Upon assessment changes noted to wound. Measurements note 4 cm x 4 cm x 0.5 cm. Noted tunneling at 9 o'clock at 0.2 cm .NP(Nurse Practitioner) notified and awaiting new orders During an interview on 7/17/19 at 3:31 p.m., the second floor unit manager indicated wound assessments and measurements should have been documented in the EHR (Electronic Health Record.) During an interview on 7/17/19 at 3:45 p.m., the first floor unit manager LPN 2 indicated wound assessments should have been documented by the floor nurse in the EHR after each dressing change and by the wound nurse each Thursday. A facility document, not in the clinical record, titled, Pressure Ulcer Tracking Log, provided by the Administrator on 7/15/19 at 3:50 p.m., indicated the following; 1. On 6/27/19 Resident 46's coccyx wound measured 4 cm (centimeters) in length, 3 cm in width and 0.1 cm in depth. 2. On 7/5/19 Resident 46's coccyx wound measured 4 cm in length, 4 cm in width and 0.1 cm in depth. 3. On 7/11/19 Resident 46's coccyx wound measured 4 cm in length, 4 cm in width and 0.1 cm in depth. The Resident's record did not include these measurements and the facility was unable to provide wound assessments to correlate with these dates. A survey document titled, Entrance conference worksheet Electronic Health Record (EHR) Information, provided by the Administrator on 7/14/19 at 1:47 p.m., indicated, .Provide specific instructions on where and how surveyors can access the following information in the EHR (or in the hard copy if using split EHR and hard copy system) .1.Pressure ulcers .EHR .Clinical Tab - Chart View Tab - Select Member - Wounds Tab A facility document titled, Pressure Ulcer Prevention & Management, provided by the Assistant Director of Nursing on 7/18/19 at 1:35 p.m., indicated, .Wounds are assessed to location, type, stage, size, shape, depth, size and depth of sinus track, surrounding tissue, and drainage (type, color, odor, and amount), wound bed, wound edges, progress towards healing, signs of infection, treatment plan, and related pain .weekly progress will be documented by the nurse to asses type, stage, size, shape, depth, size and depth of sinus track, surrounding tissue, and drainage (type, color, odor, and amount), wound bed, wound edges, progress towards healing, signs of infection, treatment plan, and related pain .If progress is not noted in three (3) weeks or deterioration is present, the physician is notified for treatment order review 3.1-40

Based on record review and interview the facility failed to provide medication as ordered by the physician for 1 of 3 residents reviewed for medication distribution (Resident B ). Resident B did not receive 9 doses of a medication used to treat [MEDICAL CONDITION] hypertension and was subsequently sent to the emergency room and admitted to the hospital for Acute and Chronic Diastolic Heart Failure and Acute and Chronic Hypoxic [MEDICAL CONDITION]. Findings include: The record for Resident B was reviewed on 3/11/2019 at 3:37 p.m. Resident B [DIAGNOSES REDACTED]. A discharge order from the hospital on [DATE] indicated macitentan (opsumit) 10 mg (milligrams) oral (PO) daily. An admission order dated 12/28/2018 indicated macitentan (opsumit) 10 mg tablet/ 1 tablet oral (PO) daily/start date 12/29/2018 for [MEDICAL CONDITION] hypertension. During an interview on 3/12/2019 at 1:20 p.m., with LPN 5, she indicated the resident medication orders were sent to the Pharmacy (RX) on 12/28/2019. The medication order had to be sent to a specialty pharmacy to dispense to the facility for the resident. She indicated she talked with the facility RX and they indicated 3-5 days for delivery time to the facility. She indicated the medication was never received and the resident did not receive the medication. She indicated the Medical Director was aware the medication had not been received and was aware the medication order was sent to a specialty RX for dispensing. The resident and the family were informed of the medication situation and the difficulty obtaining the medication. The family offered to bring in medication from home and give to the resident but she told the family it was the facility practice to not dispense medications unless they were dispensed from the RX. She indicated the resident was monitored for signs and symptoms of distress. An email, dated 12/30/2018, sent to the facility by the facility pharmacy (RX) indicated .The above drug is a specialty medication and requires dispensing by a specialty pharmacy. We have notified our Specialty Pharmacy and their representative will be in contact with you within the next 24 hours to discuss next steps During an interview, on 3/12/2019 at 11:54 a.m., with the Medical Director, she indicted she was aware of the medication situation and the facility was working with the RX to get the medication for the resident. She indicated the resident was in no distress until 1/4/2019 when the resident was placed on oxygen and given [MEDICATION NAME] for her [MEDICAL CONDITION], then on 1/5/2019 in the evening she was in distress and sent to hospital 1/6/2019 for possible cardiac issues. During an interview, on 3/13/209 at 3:49 p.m., with the facility RX representative, he indicated an email dated 12/30/2018 had been sent to the facility indicating the medication had to be sent to another specialty RX for dispensing. He indicated the email informed the facility the specialty RX would contact them in 24 hours regarding the dispensing of the medication for the resident. During an interview, on 3/13/2019 at 3:58 p.m., with the Director of Nursing, he indicated he never was contacted by the specialty RX. He indicate his nursing staff contacted the facility RX and were told the medication would be sent in 3 to 5 business days from the RX. During an interview, on 3/13/209 at 4:05 p.m., with the representative from the specialty RX she indicated the resident was not in the system and she indicated they did not inform the facility. She indicated she sent the order to another group to approve the dispensing of the medication and that there was no follow-up from the specialty RX to the facility RX. A Nurse Practitioner assessment note on 1/4/2019 indicated the resident was on opsumit and tadalafil and would continue therapy however opsumit was not being given because the facility Medical Director was not a licensed prescriber for the medication and Medicare did not allow patients to bring in their own meds and would continue to have ongoing discussions with the facility about solutions. The Medication Review Record (MAR) indicated Resident B did not receive opsumit between 12/29/18-1/6/19, when she was sent to the emergency room . A Nursing Progress note, on 1/4/2019 at 3:05 a.m., indicated the resident had oxygen saturation in the low 80% and she was given 2 liters of oxygen. Her oxygen levels increased to 92% and the resident did not complain of shortness of breath (SOB). A Nursing Progress note, on 1/4/2019 at 5:37 a.m., indicated the resident had been given [MEDICATION NAME] (diuretic) 20 mg for her bilateral lower leg, 2+ [MEDICAL CONDITION]. A Nursing Progress note, on 1/4/2019 at 2:38 p.m., indicated the resident had no [MEDICAL CONDITION] noted. A Nursing Progress note, on 1/4/2019 at 5:01 p.m., indicated the resident had been given 40 mg of [MEDICATION NAME] for bilateral lower leg [MEDICAL CONDITION] and SOB. A Nursing Progress note, on 1/5/2019 at 10:41 p.m., indicated the resident's oxygen saturation was at 87% on 2 liters of oxygen and lung sounds were clear to auscultation. The resident did complain of SOB with respirations of 20. The physician was notified gave and new orders for a chest x-ray and labs. An order from the physician indicated to titrate oxygen to get the resident saturation level to above 90%. The resident's oxygen was increased to 4 liters and her saturation level remained at 87 to 88%. A Nursing Progress note, on 1/6/2019 at 12:37 a.m., indicated the resident's oxygen saturation level was 86% on 5 liters of oxygen and her respirations were at 22. The physician was notified and new orders for resident transport to the ER (emergency room ) for evaluation and treatment were received. The ER report dated 1/6/2019 indicated the resident was sent to the hospital for shortness of breathe and [MEDICAL CONDITION]. The ER note indicated the resident was admitted to the hospital. The assessment and plan indicated 1:Acute and Chronic Diastolic Heart Failure and 2: Acute and Chronic Hypoxic [MEDICAL CONDITION]. The assessment indicated the Acute and Chronic Hypoxic [MEDICAL CONDITION] was suspect to mostly be due to the Acute and Chronic Diastolic Heart Failure but also had the component of the resident being off her opsumit medication while at the facility. A current policy titled Accepting Delivery of Medications received from the Assistant Director of Nursing (ADON) on 3/13/2019 at 2:00 p.m. indicated .Medications will only be accepted from an approved dispensing pharmacy .6. The dispensing pharmacy, consultant pharmacist, and the Director of Nursing Services shall be notified of medication order errors This Federal tag related to complaint IN 985. 3.1-48(c)(2)

Based on observation, interview and record review, the facility failed to notify the physician of lack of bowel movements and diarrhea stools for 7 of 9 residents reviewed for notification of change of condition. (Residents #39, #12, #105, #115, #136, #192, and #65). This deficient practice resulted in Resident #39 being hospitalized with a [DIAGNOSES REDACTED]. Resident #12 had 8 days without a bowel movemet with no physician notification and was admitted to the hospital with [REDACTED]. Findings include: 1. On 5/27/15 at 10:56 a.m., the record review for Resident #39 was completed. [DIAGNOSES REDACTED]. The Elimination Record indicated the following: 3/1/15 through 3/4/15 (4 days)- there was no elimination documentation recorded. 3/5/15- Extra Large Loose bowel movement and a medium soft formed bowel movement. 3/6/15- Extra Large softly formed x 2, one Extra large loose and one small loose stool. 3/7/15- Extra Large soft formed stool 3/8/15- One medium loose stool. One Extra large and one large softly formed stool. 3/9/15- Extra Large softly formed stool. 3/10/15- One medium softly formed stool and one extra large and one large loose stool. The Medication Administration Record [REDACTED]. The nurses notes for March 2015 had no documentation regarding notification of the physician regarding the frequency of loose stools. The resident had an episode of unresponsiveness on 3/11/15 which resulted in her being sent to the hospital. The resident was sent to the hospital on [DATE], and the discharge summary indicated, .Discharge [DIAGNOSES REDACTED]. 2. Syncopal episode. The patient hardly arousable, patient quite dehydrated. 3. Dehydration 4. Diarrhea, no stools since she has been here in the hospital .5. Acute kidney injury, Creatinine 1.6, now down to 1.1 .8. Dementia .Observation Summary: who was in her normal state of brain function before lunch yesterday when her grandson came back about 45 minutes later and found that she was not easily resposible(sic) .She was seen by a provider at (name of facility) who told the grandson that he saw no focal neuro findings, The patient had no focal neuro findings when she came here, but was found to be quite dehydrated . patient felt much better with fluid hydration and had no further syncopal episode The nurses notes for February and March 2015, had no documentation regarding notification of physician regarding the frequency of loose stools. As of exit on 5/28/15, there was no information regarding notification of physician regarding loose stools provided. 2. The record for Resident #12 was reviewed on 5/22/15 at 1:06 p.m. [DIAGNOSES REDACTED]. The resident did not have BM's documented for the following days: 5/8/15 through 5/15/15 (8 days) No documentation was found in the resident's record to indicate the physician was notified she had not had a BM in over 3 days. The resident's physician orders [REDACTED]. 7/22/13--Milk of Magnesia (a laxative medication) 400 mg (milligrams) /5 ml (milliliters) (30 ml) by mouth as needed for constipation daily. No abdominal assessments were found documented for the days the resident did not have a BM. Resident #12's record lacked documentation to indicate PRN laxatives were administered when she went without a BM longer than 3 days. A Nursing progress note dated 5/16/15 at 4:56 a.m., indicated the resident was admitted to the hospital. A CT Scan of the Abdomen and Pelvis without contrast report dated 5/17/15, indicated, .There is a very large amount of colonic stool distending the rectum to a diameter of 11 cm consistent with fecal impaction. There is additional stool present in the right colon along with moderate [MEDICATION NAME] distention A Hospital Discharge Summary with a discharge date [DATE], indicated the resident was hosptalized on [DATE], after a fall at the facility and she was admitted to the hospital for treatment of [REDACTED]. The resident's discharge [DIAGNOSES REDACTED]. Pertinent Studies included, but were not limited to, CT Scat of the abdomen and pelvis without contrast, which indicated there was a fecal impaction in the rectum. The course of her hospital stay included, but was not limited to, .2. Urinary Obstruction: On initial admission, patient grimaced to palpation of the abdomen. Bladder scan revealed that she had approximately 1.7 liters of urine in her bladder. We placed a Foley catheter that drained closer to 2 liters of fluid. The patient also had frank hematuria following this. Suspected she bled due to over distention of the bladder. Her hemoglobin did acutely drop from 8.8 on admission down to 7.4. Due to the extremity dark color of urine as well as suspected rapid bleeding, she was given 1 unit of blood. Her hemoglobin the day of discharge was 7.8. Her urine was returning clear on the day of discharge and the Foley was discontinued. It is suspected that she have an obstruction from a large fecal impaction that was about 11 cm on the CT Scan. 3. Fecal Impaction. this was found on the CT scan as noted to be about 11 cm. We tried multiple enemas including tap water, soapsuds and Fleet's and we have also manually disimpacted her about 3 days in a row. There is still a small amount of stool in the rectum as far as we can tell, although it seems the majority of the impaction has resolved. Continue to follow this as an outpatient to ensure she is passing stools appropriately. I suspect this is why she developed a urinary obstruction 3. The record for Resident #105 was reviewed on 5/27/15 at 5:30 p.m. [DIAGNOSES REDACTED]. The resident did not have BM's documented for the following days: 4/16/15 through 4/19/15 (4 days) 5/17/15 through 5/20/15 (4 days) No documentation was found in the resident's record to indicate the physician was notified she had not had a BM in over 3 days. 4. The record for Resident #115 was reviewed on 5/27/15 at 2:46 p.m. [DIAGNOSES REDACTED]. The resident did not have BM's documented for the following days: 4/9/15 through 4/13/15 (5 days) 4/21/15 through 4/25/15 (5 days) No documentation was found in the resident's record to indicate the physician was notified she had not had a BM in over 3 days. During an interview on 5/28/15 at 11 a.m., the DON (Director of Nursing) indicated she did not have any information to provide, which indicated the resident had BM's or PRN laxative medication were administered after the resident went without BM's for 3 days during the time periods listed above. 5. The record for Resident #136 was reviewed on 5/27/15 at 5:16 p.m. [DIAGNOSES REDACTED]. The resident did not have BM's documented for the following days: 5/12/15 through 5/22/15 (11 days) No documentation was found in the resident's record to indicate the physician was notified she had not had a BM in over 3 days. 6. The record for Resident #192 was reviewed on 5/27/15 at 5:02 p.m. [DIAGNOSES REDACTED]. The resident did not have BM's documented for the following days: 5/3/15 through 5/6/15 (4 days) 5/12/15 through 5/16/15 (5 days) 5/20/15 through 5/24/15 (4 days) No documentation was found in the resident's record to indicate the physician was notified she had not had a BM in over 3 days. On 5/27/15 at 12:45 p.m., during interview, the DON indicated she was not sure if the physician was notified if Residents #12, #105, #115, #136 and #192 had BM's after 3 days during time the periods listed above, but she was having the ADON look for that information and she would provide whatever information she was able to locate. On 5/28/15 at 4:35 p.m., the DON indicated she did not locate any information in the records, which indicated the physician had been notified regarding Residents #12, #105, #115, #136 and #192 going without a BM for 3 days. During an interview on 5/28/15 9:31 a.m., LPN #22 indicated the bowel protocol was the night shift pulled up the list of residents and if a resident had not had a BM in 3 days, that resident received a bowel assessment, which consisted of checking for distention of the abdomen and bowel sounds. She indicated the resident received Milk of Magnesia (a laxative medication) from the dayshift nurse, then if he or she did not have a BM by the end of dayshift, the evening nurse gave the resident a Duloclax suppository (a laxative medication). She indicated if there were no results by the end of the evening shift, then the nightshift nurse gave the resident an enema (a medication given rectally to help loosen the stool in the bowel). If the resident still had no results after the enema, then the physician was suppose to be notified. 7. On 5/26/15 at 4:09 p.m., record review for Resident #65 was completed. [DIAGNOSES REDACTED]. The resident Elimination Records indicated the resident had no bowel movements on the following dates: March 2015 3/3/15 through 3/9/15 (7 days) 3/16/15 through 3/21/15 (6 days) April 2015 4/11/15 through 4/15/15 (4 days) 4/18/15 through 4/24/15 (7 days) The Medication Administration Record [REDACTED]. The resident had orders for [MEDICATION NAME] (a laxative medication) 10 milligrams as needed one time for constipation, but it had not been documented as given. The Medication Administration Record [REDACTED]. She also received a Fleets enema (a medication given rectally to help loosen stool in the bowel) on 4/17/15. There was an order for [REDACTED]. May 2015 5/15/15 through 5/25/15 (11 days) The Medication Administration Record [REDACTED]. The order was changed for [MEDICATION NAME] Sodium 100 milligrams three times daily on 5/18/15. She also received Senna Laxative 8.6-50 mg (2 tablets) twice daily. The resident received 30 milliliters of [MEDICATION NAME] orally every two days starting 5/19/15. The Medication Administration Record [REDACTED]. She also received MOM on 5/25/15 at 8:21 a.m. and had results at 9:21 a.m. The nurses notes dated 5/18/15 through 5/23/15, did not indicate the resident had a bowel movement (BM). As of the exit conference on 5/28/15 at 5:40 p.m., there was no other BM documentation provided. A current policy titled In Service-Bowel Protocol undated, provided by the DON on 5/27/15 at 2:57 p.m., indicated Bowel Protocol: All residents are to have Physician orders [REDACTED]. On a daily basis a licensed nurse is to review the resident's bowel movements to ensure prompt intervention to prevent constipation. Every Bowel Movement is to be documented in the Clinical Record, including the size and character of the stool. Initiation of a bowel protocol is to be documented in the clinical record, and documentation should continue every shift until a BM occur . Notify MD (Medical Doctor) of Residents who have had no response to the Bowel Interventions from the previous day-implement New Orders if given 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure bowel movements (BM's) were monitored and assessments were completed for 7 of 9 residents reviewed for bowel monitoring. (Residents #12, #39, #105, #115, #136, #192, and #65). This deficit practice resulted in Resident #12 developing an 11 (cm) centimeter fecal impaction, which required 3 days to disimpact with multiple interventions and hospitalization . This deficit practice, also resulted in Resident #39 being hospitalized due to diarrhea stools with a [DIAGNOSES REDACTED]. Findings include: 1. On 5/22/15 at 10:29 a.m., Resident #12 was observed sitting in her wheelchair in front of the nurses station holding the right of her abdominal area with her left hand and her head at the forehead area with her right hand. At that time, CNA #16 indicated to LPN #1 the resident had three soft BM's and her abdomen was hard. LPN #1 felt the resident's abdomen and asked if the resident was having any pain, but the resident did not respond verbally to LPN #1. The resident continued to guard her abdomen. LPN #1 indicated she was getting a stat KUB (Kidneys, Ureter and Bladder X-ray). On 5/22/15 at 10:45 a.m., a request was made to LPN #3 to have Resident #12 placed in bed and her abdomen assessed for bowel sounds as she was guarding her abdomen. LPN #3 and CNA #16 transferred the resident to bed. Resident #12 was partially laying on her left side with her bilateral legs bent up. LPN #3 attempted several times to have the resident roll onto her back and straighten out her legs, so she could assess her abdomen, but the resident stayed in the position she was laying in. LPN #3 listened to the resident's abdomen and palpated it, indicating she had hypoactive bowel sounds in the right lower quadrant (RLQ) and her abdomen was firm and distended. While LPN #3 was assessing the resident's abdomen, the resident placed her right hand over her right lower abdomen and had facial grimacing. At that time, LPN #3 asked her if she was having pain and Resident #12 indicated she was not having abdominal pain, but she continued to guard her right lower abdomen with facial grimacing. LPN #3 indicated the resident had a small amount of emesis last evening and only ate 10% for her breakfast this morning. On 5/22/15 at 12:45 p.m., LPN #3 and #4 went into the resident's room to assess the resident's stool due to a concern she had a black stool. LPN #3 and LPN #4 pulled the resident's brief down and a brown mushy colored stool was observed in her brief. LPN #3 indicated at that time, the resident's abdomen was harder now then it was earlier. The record for Resident #12 was reviewed on 5/22/15 at 1:06 p.m. [DIAGNOSES REDACTED]. The resident's physician orders [REDACTED]. 7/22/13--Milk of Magnesia (a laxative medication) 400 mg (milligrams) /5 ml (milliliters) (30 ml) by mouth as needed for constipation daily. The resident did not have BM's documented for the following days: 5/8/15 through 5/15/15 (8 days) No abdominal assessments were found documented for the days the resident did not have a BM. Resident #12's record lacked documentation to indicate PRN laxatives were administered when she went without a BM longer than 3 days. A Nursing progress note dated 5/16/15 at 4:56 a.m., indicated the resident was admitted to the hospital. A CT Scan of the Abdomen and Pelvis without contrast report dated 5/17/15, indicated, .There is a very large amount of colonic stool distending the rectum to a diameter of 11 cm consistent with fecal impaction. There is additional stool present in the right colon along with moderate [MEDICATION NAME] distention A Hospital Discharge Summary with a discharge date [DATE], indicated the resident was hosptalized on [DATE], after a fall at the facility and she was admitted to the hospital for treatment of [REDACTED]. The resident's discharge [DIAGNOSES REDACTED]. Pertinent Studies included, but were not limited to, CT Scat of the abdomen and pelvis without contrast, which indicated there was a fecal impaction in the rectum. The course of her hospital stay included, but was not limited to, .2. Urinary Obstruction: On initial admission, patient grimaced to palpation of the abdomen. Bladder scan revealed that she had approximately 1.7 liters of urine in her bladder. We placed a Foley catheter that drained closer to 2 liters of fluid. The patient also had frank hematuria following this. Suspected she bled due to over distention of the bladder. Her hemoglobin did acutely drop from 8.8 on admission down to 7.4. Due to the extremity dark color of urine as well as suspected rapid bleeding, she was given 1 unit of blood. Her hemoglobin the day of discharge was 7.8. Her urine was returning clear on the day of discharge and the Foley was discontinued. It is suspected that she have an obstruction from a large fecal impaction that was about 11 cm on the CT Scan. .3. Fecal Impaction. this was found on the CT scan as noted to be about 11 cm. We tried multiple enemas including tap water, soapsuds and Fleet's and we have also manually disimpacted her about 3 days in a row. There is still a small amount of stool in the rectum as far as we can tell, although it seems the majority of the impaction has resolved. Continue to follow this as an outpatient to ensure she is passing stools appropriately. I suspect this is why she developed a urinary obstruction A KUB report dated 5/22/15, indicated .There is evidence of a colonic ileus and constipation. Continued close clinical correlation is advised and follow-up would be warranted The resident's progress notes indicated the following: 5/20/15 at 11:15 p.m., indicated the resident was readmitted to the facility after hospitalization . 5/21/15 at 6:15 p.m., indicated the resident had a moderate amount of dark brown emesis and a minimal amount of dark brown stool. 5/22/15 at 10:49 a.m., indicated the doctor was notified of the resident's abdominal pain, bloating and diarrhea. A new order for a KUB was given. The staff reported the resident had three episodes of loose stools and was restless and holding her abdomen. When her abdomen was assessed it was firm and tender to touch. The resident had not eaten any solid foods for breakfast. 5/22/15 at 11:39 a.m., indicated the resident's bowel sounds were auscultated in all four quadrants and were hypoactive in the RLQ. The resident was guarding that area with facial grimacing while laying with limited extension of legs and partially laying on her left side. Her abdomen was firm and distended when palpated. 5/22/15 at 1:37 p.m., indicated the KUB was completed. Resident #12 had one loose brown stool. Her bowel sounds were auscultated and was hypoactive. She was assisted up into her wheelchair by two staff members and was guarding her right side with her arm and leaning to the right. 5/22/15 at 7:57 p.m., indicated the results of the KUB indicated the resident had a colonic ileus and constipation. The doctor was notified and a fleets enema was ordered now for constipation/ileus. The resident had hypoactive bowel sounds and her appetite was poor. She refused staff feeding assistance. A late entry note dated 5/23/15 at 3:25 a.m., indicated two CNA's that had given care to the resident on 5/21/15 at 3:00 a.m., had reported the resident had an extra large amount of BM and brown colored emesis, which was foul smelling once at the same time as the BM. 2. On 5/27/15 at 10:56 a.m. the record review for Resident #39 was completed. [DIAGNOSES REDACTED]. The Elimination Record indicated the following: February 2015, the resident had from 1-3 softly formed or loose stools daily ranging from small to extra large. 3/1/15 through 3/4/15 (4 days)- there was no elimination documentation recorded. 3/5/15- Extra Large Loose bowel movement and a medium soft formed bowel movement. 3/6/15- Extra Large softly formed x 2, one Extra large loose and one small loose stool. 3/7/15- Extra Large soft formed stool 3/8/15- One medium loose stool. One Extra large and one large softly formed stool. 3/9/15- Extra Large softly formed stool. 3/10/15- One medium softly formed stool and one extra large and one large loose stool. The Medication Administration Record [REDACTED]. The resident was sent to the hospital on [DATE] after an episode of unresponsiveness, and the discharge summary indicated, .Discharge [DIAGNOSES REDACTED]. 2. Syncopal episode. The patient hardly arousable, patient quite dehydrated. 3. Dehydration 4. Diarrhea, no stools since she has been here in the hospital .5. Acute kidney injury, Creatinine 1.6, now down to 1.1 .8. Dementia .Observation Summary: who was in her normal state of brain function before lunch yesterday when her grandson came back about 45 minutes later and found that she was not easily resposible(sic) .She was seen by a provider at (name of facility) who told the grandson that he saw no focal neuro findings, The patient had no focal neuro findings when she came here, but was found to be quite dehydrated . patient felt much better with fluid hydration and had no further syncopal episode The nurses notes for February and March 2015, had no documentation regarding notification of physician regarding the frequency of loose stools. During interview on 5/28/15 at 12:39 p.m., the Director of Nursing (DON) indicated the resident had been given medication for the diarrhea. The Medication Administration Record [REDACTED]. These orders were post hospitalization . There were no other medications to help with diarrhea found in the documentation. 3. The record for Resident #115 was reviewed on 5/27/15 at 2:46 p.m. [DIAGNOSES REDACTED]. The resident's Electronic Medication Administration Record [REDACTED] 10/16/13--[MEDICATION NAME] Suppository 10 mg rectally PRN every 3 days for constipation 10/16/13--[MEDICATION NAME] Sodium 100 mg by mouth PRN daily for constipation 10/16/13--Milk of Magnesia mint 400 mg/5 ml (30 ml) by mouth PRN every 3 days for constipation The resident did not have BM's documented for the following days: 4/9/15 through 4/13/15 (5 days) 4/21/15 through 4/25/15 (5 days) No abdominal assessments were found documented for the days the resident did not have a BM. Resident #115's record lacked documentation to indicate PRN laxatives were administered when she went without a BM for longer than 3 days. During an interview on 5/28/15 at 11 a.m., the DON indicated she did not have any information to provide, which indicated the resident had BM's or PRN laxative medication were administered after no BM for 3 days during the time periods listed above. 4. The record for Resident #136 was reviewed on 5/27/15 at 5:16 p.m. [DIAGNOSES REDACTED]. The resident's EMAR dated May 2015, included, but were not limited to, the following orders: 5/6/15--[MEDICATION NAME] 10 mg suppository rectally as needed daily for constipation 5/6/15--Milk of Magnesia 400 mg/5 ml (30 ml) daily PRN by mouth for constipation. 5/6/15--[MEDICATION NAME] Sodium-Senna (stool softener) 8.6-50 mg 1 tablet PRN twice daily for constipation. 5/7/15--[MEDICATION NAME] (a laxative medication) 17 grams PRN daily starting 5/10/15 for constipation. The resident did not have BM's documented for the following days: 5/12/15 through 5/22/15 (11 days) No abdominal assessments were found documented for the days the resident did not have a BM. Resident #136's record lacked documentation to indicate PRN laxatives were administered when she went without a BM for longer than 3 days. An admission Nursing Evaluation dated 5/6/15, indicated the resident's usual pattern of BM's were every two days. On 5/27/15 at 12:24 p.m., the ADON provided information on a BM Tracking Form, which indicated the resident was administered Milk of Magnesia on the following dates: 5/15/15--no results were documented 5/22/15--no results were documented 5/23/15--the resident had a BM on 5/23/15 On 5/27/15 at 12:24 p.m., the ADON provided a partial copy of Resident #105's EMAR dated April 2015, with the following medications which included, but were not limited to the following: 5/6/15--Milk of Magnesia 400 mg/5 ml (30 ml) daily PRN by mouth for constipation. At that time, the ADON indicated the information he provided was all the information he had on the resident's BM's and any PRN laxatives she may have been given. 5. The record for Resident #192 was reviewed on 5/27/15 at 5:02 p.m. [DIAGNOSES REDACTED]. The resident's EMAR dated May 2015, included, but were not limited to, the following orders: 5/1/15--[MEDICATION NAME] 10 mg suppository rectally PRN every day for constipation. 5/1/15-- Milk of Magnesia 400 mg/5 ml (30 ml) suspension by mouth PRN daily for constipation. 5/4/15--Senna 8.6 mg by mouth twice daily PRN for constipation. No abdominal assessments were found documented for the days the resident did not have a BM. Resident #192's record lacked documentation to indicate PRN laxatives were administered when she went without a BM for longer than 3 days. The resident did not have BM's documented for the following days: 5/3/15 through 5/6/15 (4 days) 5/12/15 through 5/16/15 (5 days) 5/20/15 through 5/24/15 (5 days) On 5/27/15 at 12:24 p.m., the ADON provided a partial copy of Resident #192's EMAR dated May 2015, with the following medications which included, but were not limited to the following: 5/1/15--[MEDICATION NAME] 10 mg suppository rectally PRN every day for constipation. 5/1/15-- Milk of Magnesia 400 mg/5 ml (30 ml) suspension by mouth PRN daily for constipation. At that time, the ADON indicated the information he provided was all the information he had on the resident's BM's and any PRN laxatives she may have been given. 6. On 5/26/15 at 4:09 p.m., record review for Resident #65 was completed. [DIAGNOSES REDACTED]. The resident Elimination Records indicated the resident had no bowel movements on the following dates: March 2015 3/3/15 through 3/9/15 (7 days) 3/16/15 through 3/21/15 (6 days) April 2015 4/11/15 through 4/15/15 (4 days) 4/18/15 through 4/24/15 (7 days) The Medication Administration Record [REDACTED]. The resident had orders for [MEDICATION NAME] (a laxative medication) 10 milligrams as needed one time for constipation, but it had not been documented as given. The Medication Administration Record [REDACTED]. She also received a Fleets enema (a medication given rectally to help loosen stool in the bowel) on 4/17/15. There was an order for [REDACTED]. May 2015 5/15/15 through 5/25/15 (11 days) The Medication Administration Record [REDACTED]. The order was changed for [MEDICATION NAME] Sodium 100 milligrams three times daily on 5/18/15. She also received Senna Laxative 8.6-50 mg (2 tablets) twice daily. The resident received 30 milliliters of [MEDICATION NAME] orally every two days starting 5/19/15. The Medication Administration Record [REDACTED]. She also received MOM on 5/25/15 at 8:21 a.m., and had results at 9:21 a.m. The nurses notes dated 5/18/15 through 5/23/15, did not indicate the resident had a bowel movement (BM). As of the exit conference on 5/28/15 at 5:40 p.m., there was no other BM documentation provided. During an interview on 5/28/2015 at 9:23 a.m., CNA #21 indicated she documented the BM's on the electronic charting in the computer. She indicated she documented the BM's as often as the residents had a BM. She indicated she tried to document right after the resident had the BM because she was forgetful and she might forget the resident had the BM. She indicated if the resident did not have a BM for that shift she notified the nurse and she charted they did not have one in the electronic charting in the computer. She indicated in the electronic charting there was a place for stool, urine or stool and urine and a staff member was able to check what one type of toileting applied to the resident. She indicated if the staff member did not check the resident had a BM for that shift, then there would be no documentation in the computer indicating the resident had a stool. During an interview on 5/28/15 9:31 a.m., LPN #22 indicated the bowel protocol was as follows: the night shift nurse pulled up the list of residents and if a resident had not had a BM in 3 days, that resident received a bowel assessment, which consisted of checking for distention of the abdomen and auscultating bowel sounds. She indicated the resident received Milk of Magnesia from the dayshift nurse, then if he or she had not had a BM by the end of dayshift, the evening nurse gave the resident a Duloclax suppository. She indicated if there were no results by the end of the evening shift, then the nightshift nurse gave the resident an enema. If the resident still had no results after the enema, then the physician was suppose to be notified. She indicated if a resident complained of constipation, nausea or vomiting, she would check to see if they had a BM and do a bowel assessment and look to see if he or she had a related [DIAGNOSES REDACTED]. She indicated if the symptoms were not relieved, then she would call the physician or give medications if the resident had medications ordered. If the resident had a [DIAGNOSES REDACTED]. She indicated what she did depended on whether or not the resident had a BM and what kind of symptoms the resident was displaying, because she might opt to call the physician first. A current policy titled Change in Resident's Condition dated 1/31/15, provided by the DON on 5/27/15 at 2:57 p.m., indicated Policy Statement: (Name of facility) will notify the resident, his or her attending physician and responsible party of changes in the resident's medical/mental condition and/or status . Procedure: . Non-immediate Notification (Subacute) Problems: . Nursing Documentation: A. Any calls to or from physicians will be documented in the nurses notes indicating information conveyed or received . D. Acute and subacute problems are to be communicated shift to shift by verbal report and highlighting or discussing the problems listed on the 24 hour shift report to facilitate communication A current policy titled In Service-Bowel Protocol undated, provided by the DON on 5/27/15 at 2:57 p.m., indicated Bowel Protocol: All residents are to have Physician orders [REDACTED]. On a daily basis a licensed nurse is to review the resident's bowel movements to ensure prompt intervention to prevent constipation. Every Bowel Movement is to be documented in the Clinical Record, including the size and character of the stool. Initiation of a bowel protocol is to be documented in the clinical record, and documentation should continue every shift until a BM occurs. The Bowel intervention protocol should be completed according to the following schedule: Night Nurse: Review the BM report and list the names of the Residents who have had no BM for 3 days. List the names of the Residents who have had no response to the Bowel Interventions from the previous day. Turn the BM Tracking Form the previous day into the Unit Manager. Day Nurse: Assess Resident for need of MOM (Milk of Magnesia) . Notify MD (Medical Doctor) of Residents who have had no response to the Bowel Interventions from the previous day-implement New Orders if given. Administer MOM . Evening Nurse: Administer Suppository (per order) to any Residents with no response to the MOM . Aids: Aides are to record all BM's for every Resident on the clinical tracking form and to inform nurse if resident fails to have BM in a 3 day period 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure fall prevention interventions were implemented and communicated to staff to prevent falls for 3 of 5 residents reviewed for accidents and supervision. (Residents #71, #12, and #48) . This deficient practice resulted in Resident #71 sustaining a right hip fracture requiring surgery to have the fracture stabilized. This deficit practice also resulted in Resident #12 sustaining facial abrasions and bruising with the largest measurement being 7.0 cm (centimeters) x 5.6 cm with a visit to the emergency room . Findings include: 1. On 5/22/15 at 11:11 a.m., Resident #71 was observed laying in bed with a wedge pillow between his legs and an ace wrap from his right knee to his right hip. His right knee was edematous and had purple colored bruising. At that time, during interview CNA #23 indicated the resident returned from the hospital about a week ago because he fell and broke his hip and had to have surgery to repair it. The record for Resident #71 was reviewed on 5/26/15 at 10:29 a.m. [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated the resident required extensive assist with one person physical assist for transfers and limited assist with one person physical assist to walk in his room or the corridors. The resident had a Care Plan dated 8/29/14, which addressed the problem he was at risk for falls due to he had impaired judgement of safety and a history of syncopal episodes, history of falls and a fall with a fracture. Interventions included, but were not limited to, . Ensure he is wearing proper footwear while out of bed . 3/8/15--Non-skid socks while in bed. All nursing staff education provided on appropriate criteria for low bed usage, 4/30/15--Ensure room is appropriate temperature . low bed. The resident's progress notes indicated the following regarding his falls: 3/15/15 at 12:46 p.m., indicated the resident was witnessed standing at the nurses station and attempted to pivot and turn and fell on his right side. He received a skin tear to his right elbow that measured 0.4 x 1.2 cm. He had AROM (active range of motion) to all extremities but complained of soreness to his right side. He was able to stand without added discomfort. He lifted his bilateral knees. 3/17/15 at 3:46 p.m., indicated IDT review for fall . Witnessed fall occurred on 3/15/15 at 1255 p.m Resident was observed at the nurses station attempting to pivot and turn when he lost his balance and fell on his right side. Resident unable to explain what he was attempting to do, where he was trying to go. Upon assessment. Resident noted to have a skin tear to right elbow, first aid performed to area. Root cause identified as progressive decline w (with) /[DIAGNOSES REDACTED]. Interventions: staff education provided on [DIAGNOSES REDACTED]-decrease stimulation, specific factors that increase risk for falls (vision, physical declines, cognitive declines.) A Staff Education document titled [DIAGNOSES REDACTED] In-Service dated March 2015, indicated nursing staff were educated on Lewy Body by signing in for the in-service. A document titled Lewy Body indicated .Interventions: Low stimulation areas, Frequent observations-anticipating needs 3/17/15 at 2:41 p.m., the resident yelled out in pain, had facial grimacing and guarded his RLE (right lower extremity) when assisted with dressing. He was unable to bear weight to his RLE. He would not allow staff to perform PROM (passive range of motion) to the RLE. 3/17/15 at 9:31 p.m., indicated the resident was unable to bear weight on his BLE (bilateral lower extremities) and required assist of two staff members with transfers. Upon assessment he moaned with slight squeeze of his right thigh and with transfers. An X-ray of the right hip, thigh and knee was negative for a fracture. 3/24/15 at 12:55 p.m., indicated the resident complained of pain when RLE moved and facial grimacing and guarding his right leg. There was faint yellowish bruising remained to his right thigh. He was assisted into his wheelchair with use of a Hoyer lift with staff assist of 4. A new order for a CT scan of the pelvis and right hip and right thigh and leg was received due to complaints of severe pain after a fall. 3/26/15 at 11:35 p.m., the physician called and indicated the resident needed to go to the hospital ER. 3/27/15 at 4:29 a.m., indicated the resident was taken to the hospital ER at 11:40 p.m. Results from CT scan indicated a comminuted fracture of the greater trochanter of the proximal femur was seen. The ER physician called the facility after assessing the resident and indicated there was nothing that could be done for the resident because it was a non-surgical injury. He was brought back to the facility at 3:00 a.m., with orders for non-weight bearing on the right side and to follow up with orthopedic doctor in 10-14 days for consultation. 4/21/15 indicated a new order for weight bear on BLE as tolerated was received. 4/22/15 at 4:12 p.m., indicated the resident was found sitting beside his bed on his bottom with his legs extended out. The resident had on Ted hose at the time of the fall and no non-skid footwear. He was lying in bed prior to the fall. A Nursing Staff In-Service document titled Low Bed Criteria dated April 2015, indicated staff were educated for this in-service by signing in for the in-service. A document titled Low Bed Criteria indicated We need to discuss the appropriate criteria for low bed (assessed and implemented by IDT (Interdisciplinary Team) mgmt (management) team) .1. resident has document roll outs of bed, multiple interventions have been attempted and failed, and the IDT (Interdisciplinary Team) mgmt (management) had determined the Fall goal has changed from preventing falls to preventing falls w (with) / injuries 2. resident is totally dependent and unable to initiate or assist with sit to stand/transfers AND is identified as fall risk for falls from bed. Problems w/Low Bed use, when not appropriate for specific resident. 1. Resident that is able to initiate/assist with sit to stand/transfers will continue to attempt to get out of bed (if desired). A low bed is almost a guaranteed fall, not many of the geriatric population have the strength to stand independently from floor level. 2. Low beds are RESTRAINTS when not used in the appropriate way. If we are using low beds to prevent the resident from getting out of bed when they desire to get up, then we are restraining them. (It is more important to identify what the need is, why are they wanting to get out of bed (toileting, hunger, bored, restless .) and put interventions in place to ensure their needs are met. Where can staff find the information on if a resident should be in a low bed? 1. RIS (Resident Information Sheet) 2. Care Plan A document titled Resident Information Sheet dated 4/22/15, indicated staff was educated on this date regarding the resident's care information updates. The care sheet indicated the resident was extensive assist with two person physical assist for transfers and mobility, had a low bed, weight bear as tolerated and was not a fall risk. 4/28/15 at 10:39 a.m., indicated IDT fall review .Unwitnessed fall occurred on 4/22/15 at 310 p.m resident found sitting on the floor at bedside. Resident stated he was having fun and he was having a difficult time trying to stand and get out of bed. Resident did not have on proper foot wear . Root cause identified as improper footwear, acute physical decline r/t (related/to) decreased mobility, bed not in correct position for transfers. (The resident's record nor the Resident Information Sheet indicated what the correct height of the bed was for the resident transfers were for this resident). Interventions: OT screen for transfers, w/c (wheelchair) mobility, keep bed at correct height for Resident. New w/c w (with) / anti-tippers, appropriate for Resident's height has been delivered. 4/30/15 at 7:37 a.m., indicated the resident was on the floor at the bedside in his room at 3:45 a.m., He was sitting in a praying like position facing towards the bed on bent knees. The bed was in a lower position than what was noted for the resident, but not all the way to the floor. (The resident's record nor the Resident Information Sheet indicated what the correct height of the bed was for the resident transfers were for this resident). He indicated he needed cold air, but was not able to describe what he was doing. Superficial abrasions were noted to his bilateral knees measured 1.0 x 1.0 cm. 5/3/14 at 4:00 a.m., indicated the resident was heard and found on the floor in the middle of the hallway at 2:00 a.m. The staff heard a resident fall and ran to investigate to see who it was and found this resident calmly sitting on the floor with his legs crossed at the shins and his right lower extremity with an outer rotation. 911 was immediately called and he was transferred to the hospital for evaluation and treatment. 5/5/15 at 11:02 a.m., indicated IDT fall review . Unwitnessed fall occurred on 4/30/15 at 345 am. Resident found kneeling at bedside, in praying position. Resident stated he needed cold air . Upon assessment, noted superficial abrasions to both knees. Root cause identified as bed not correct height for resident transfers. (The resident's record nor the Resident Information Sheet indicated what the correct height of the bed was for the resident transfers were for this resident) Interventions: Staff inservice provided on bed height, risk vs. benefits of low beds, ensure room is comfortable temperature for resident. Unwitnessed fall occurred on 5/3/15 at 2 am. Resident was found sitting in the middle of the hall. Resident had safely transferred self out of bed, and fell during ambulation more than 15 ft away from point of origin . Upon assessment , nurse noted external rotation or Rt (right) leg, Nurse dispatched EMT (Emergency Medical Technician) to transfer resident to ER for eval (evaluation) . Root cause: Resident actively participating in therapy services, rebounding from recent change in condition. The more therapy resident receives, the more he attempts to transfer and ambulate independently. Interventions will be reassessed and revised as needed upon return. 5/5/15 at 11:27 a.m., Social Service note indicated .Daughter explained that residents condition currently is R (right) hip fracture and they are deciding with resident as a family if they will operate on hip or not due to risks of surgery explained by the doctor. Daughter states that doctor reported to her that even with surgery, resident likely would not walk again due to muscle atrophy. Today we discussed that we will have interventions in place upon residents return including possible room change closer to nurses station 5/11/15 at 7:30 p.m., indicated the resident was readmitted to the facility from the hospital. A hospital Discharge Summary with a discharge date [DATE], indicated the admitting/discharge [DIAGNOSES REDACTED]. The resident's hospital course included, but was not limited to, right proximal femur fracture and he was status [REDACTED]. During an interview on 5/27/15 at 3:31 p.m., LPN #1 indicated Resident #71 had a fractured femur in March 2015, which was inoperable. She indicated he was standing next to a medication cart and went to hand the nurse something he thought he was holding in his hand and he fell down. She indicated he was ambulating independently at that time. She indicated the last time he fell , he broke his hip because he ambulated out into the hall and fell . She indicated the staff was educated on low bed criteria. She indicated since the resident returned from the hospital he had not attempted stand or ambulate on his own at that time, due to his right hip pain, which was being treated with routine pain medication. She indicated if a resident can attempt to transfer and his or her bed was placed in the low position, then the facility restrained the resident. If the resident was able to initiate a stand, then the low bed was not to be placed in the very low position, due to this contributed to injuries when the resident fell . A current Resident Information Sheet provided by LPN #1 on 5/26/15 at 11 a.m., indicated Resident #71 had a low bed and transfers and mobility were extensive assist from 2 staff members, weight bear as tolerated and he was not a fall risk. During an interview on 5/27/15 at 6:25 p.m., the Director of Nursing (DON) indicated when the resident fell and broke his hip the second time he had ambulated into the hallway, but he was not to be up ambulating independently. During an interview on 5/28/15 at 9:23 a.m., CNA #21 indicated she received the information regarding her residents' care on her Resident Care Information Sheet. She indicated if she needed to know the bed height for a resident she would look at her Resident Information Sheet to get that information. At that time, she looked at the Resident Information Sheet for residents #71 and indicated she could not find a safe transfer height listed on the sheet for these residents, so she would leave their beds in the lowest position the bed could be in. 2. On 5/22/15 at 10:29 a.m., Resident #12 was sitting in her wheelchair in front of the nurses station. She was observed to have bruising surrounding her bilateral eyes, under her eyes extending onto the top of her forehead. She was observed to have an abrasion to the bridge of her nose and to the middle of her forehead. She had bruising to her bilateral hands extending past her wrists. On 5/22/15 at 12:45 p.m., Resident #12 was observed laying on top of the blanket barefooted and her pants were pulled down around her ankles. She had a brief on. CNA #2, LPN #3 and LPN #4 came into the resident's room and LPN #3 and LPN #4 assessed the resident. On 05/22/2015 at 2:59 p.m., the resident was observed laying in bed barefooted. The record for Resident #12 was reviewed on 5/22/15 at 1:06 p.m. [DIAGNOSES REDACTED]. The resident had a Care Plan dated 7/23/13, which addressed the problem she was at risk for a fall with injury due to unstable gait at times and forgetting to use her walker. She makes unsafe decisions at times. She has a [DIAGNOSES REDACTED]. Interventions included, . Ensure she is wearing proper shoe wear when out of bed, Keep pathways clear of clutter, Offer assist with toileting as scheduled, Refer to therapy if a decline in function is noted. 9/21/13--Offer to assist with toileting and ADL's daily at 5 am, Observe for her becoming overly tired and encourage her to rest as needed. Encourage her participation in restorative program. 10/21/14--After meals, escort back to room, provide toileting and offer to lie her down in bed to rest . 4/29/15--Bed remote secured to bed. Staff coaching on care plan intervention in place for fall risk. Therapy screen for w/c positioning. Up for meals either in dining room or in stationary chair with supervision. fall mat. frequent checks. low bed. Recommend adding mattresses at bedside and room change. A current Resident Information Sheet (RIS) provided by LPN #1 on 5/26/15 at 11 a.m., indicated the resident was extensive assist with one person physical assist for transfers and mobility, she had a low bed, she was not to be left alone in her wheelchair, toilet upon rising, before and after meals, as needed and 5 a.m. if awake and she was a fall risk. The resident's progress notes and staff education indicated the following regarding her falls: 2/16/15 at 2:18 p.m., the resident was found on the floor in her room by a housekeeper. She only had her socks on when found, but her shoes were in front of her. The note indicated it appeared she was attempting to transfer herself from the w/c to bed. 2/17/15 at 12:49 p.m., the resident had an order to start physical therapy for a change in condition to work with transfers and ambulation. 2/17/15 at 12:14 p.m., indicated IDT FALL REVIEW .Unwitnessed fall occurred on 2/16/15 at approximately 145 pm. Housekeeper found resident in the room on the floor. Resident was wearing socks, w (with) /shoes on the floor in front of her, appears resident was attempting to transfer self from the w/c (wheelchair) to bed . Root cause identified as improper footwear, non-compliance with safety interventions r/t (related to) cognition, therapy screen from transfers, interventions include: therapy screen for safety with transfers w/proper footwear, Sleeping Diary x 3 days. Careplan reviewed, interventions updated-d/c (discontinue) walker in reach, d/c walk to dine, and d/c RNP (Restrorative Nursing Program) eating. 4/25/15 at 7:35 a.m., indicated the resident was found by a CNA at her bedside on the floor. She had appeared to be getting up for the day. A One-On-One Education document dated 4/27/15, indicated CNA #21 was given a teachable moment related to this resident falling due to her bed was in the low position and she was not gotten up at 5 a.m., and offered to be toileted and dressed, so she attempted to get herself up, which resulted in a fall. (The resident's record nor the Resident Information Sheet indicated what the correct height of the bed was for the resident transfers were for this resident). CNA #21 indicated the resident had her call light on and when she entered the resident's room, Resident #12 was on the floor. 4/28/15 at 10:53 a.m., indicated IDT (Interdisciplinary Team) fall review .Unwitnessed fall occurred on 4/25/15 at 615 am. Resident found sitting on the floor at bedside. Appeared resident attempted to get self out of bed. Resident was barefooted at the time of the fall . Root cause identified as improper bed height, preference for am care/toileting at 5 am not followed. Improper footwear, was barefooted. (The resident's record nor the Resident Information Sheet indicated what the correct height of the bed was for the resident transfers were for this resident). Interventions: Staff education on proper bed height, am care and toileting schedule for 5 am preference. 4/29/15 at 9.30 p.m., indicated the resident was found on the floor next to her bed by a CNA. The bed was in a very low position. A Nursing Staff In-Service document titled Low Bed Criteria dated April 2015, indicated staff were educated for this in-service by signing in for the in-service. A document titled Low Bed Criteria indicated We need to discuss the appropriate criteria for low bed (assessed and implemented by IDT (Interdisciplinary Team) mgmt (management) team) .1. resident has document roll outs of bed, multiple interventions have been attempted and failed, and the IDT (Interdisciplinary Team) mgmt (management) had determined the Fall goal has changed from preventing falls to preventing falls w (with) / injuries 2. resident is totally dependent and unable to initiate or assist with sit to stand/transfers AND is identified as fall risk for falls from bed. Problems w/Low Bed use, when not appropriate for specific resident. 1. Resident that is able to initiate/assist with sit to stand/transfers will continue to attempt to get out of bed (if desired). A low bed is almost a guaranteed fall, not many of the geriatric population have the strength to stand independently from floor level. 2. Low beds are RESTRAINTS when not used in the appropriate way. If we are using low beds to prevent the resident from getting out of bed when they desire to get up, then we are restraining them. (It is more important to identify what the need is, why are they wanting to get out of bed (toileting, hunger, bored, restless .) and put interventions in place to ensure their needs are met. Where can staff find the information on if a resident should be in a low bed? 1. RIS (Resident Information Sheet) 2. Care Plan A One-On-One Education document dated 4/29/15, indicated CNA #24 was given a teachable moment regarding using her Resident Information Sheet at all times and the resident's bed was not to be in the low position. 5/5/15 at 10:17 a.m., indicated .Unwitnessed fall occurred on 4/29/15 at approximately 9 p.m. Resident found on the mat at the side of the low bed. Resident unable to verbalize what happened or where she was attempting to go when she was getting out of bed . Root cause identified as improper bed height for transfers. (The resident's record nor the Resident Information Sheet indicated what the correct height of the bed was for the resident transfers were for this resident). Interventions: staff education provided on low bed appropriateness, risk versus benefits of low beds. Staff report independently. Maintenance refer-secure bed control remote to head board. 5/15/15 at 10:39 p.m., indicated a CNA found resident laying on her right side on the floor with her knees flexed. The resident had complaints of pain when staff tried to assist her up. She was taken to the hospital by ambulance. 5/16/15 at 4:56 a.m., indicated the resident was admitted to the hospital for a urinary tract infection and closed head injury. 5/19/15 at 10:45 a.m., IDT fall review .Unwitnessed fall occurred on 5/13/15 at approximately 715 p, Staff observed resident propelling self down hall, resident was noted to be leaning forward in w/c and fell to a prone position. Aide attempted to catch resident when she observed her falling out of w/c but was unable to reach her in time. Abrasion noted to mid-forehead and nose, bruise to forehead. Root cause identified as resident appeared tired and had poor positioning in w/c-leaning forward. Intervention: Staff coaching r/t (related to) plan of care interventions in place, therapy screen for w/c positioning. Unwitnessed fall occurred on 5/15/15 at 5:15 pm. Resident found lying on her right side on the floor at bedside. Resident pants and brief was pulled down around legs. Resident had 1 shoe on, 1 shoe off and lying in bed. Resident stated she was attempting to get up. Noted Resident's w/c at the end of the bed. Upon assessment, noted pain with rt leg movement . Root cause identified as resident left in bed at supper time. Interventions: Up for meals in dining room or if request to stay in room, up in stationary chair, supervision w/meals in dining room or resident room. .A document titled Official Employee Reprimand dated 5/13/15, indicated CNA #24 failed to follow the resident's plan of care as it was outlined on her RIS, which resulted in her falling. According to her RIS, she was to be assisted from meals, toileted and offered and assisted to lay down. The document indicated continued practice of non compliance with any resident's plan of care would result in further disciplinary action. A One-On-One Education document dated 5/14/15, indicated CNA #24 was given a teachable moment regarding interventions and Resident Information Sheets were to be followed to decrease injuries to residents, 5/20/15 at 11:15 p.m., the resident was readmitted to the facility after hospitalization after a fall. An Admission Nursing Evaluation dated 5/20/15, indicated the resident had the following areas: Right Eye Bruise-greenish yellow measured 3.2 x 1.1 cm (centimeters) Left Head Bruise-greenish yellow measured 7 x 5.6 cm Medial Nose Abrasion measured 1.7 x 0.3 cm Medial Head Abrasion measured 0.8 x 0.6 cm Right Nose Bruise-Purple/blue measured 3.0 x 2.0 cm During an interview on 5/27/15 at 3:24 p.m., LPN #1 indicated Resident #12 was admitted to the hospital on [DATE], for a urinary tract infection and a closed head injury after a fall. She indicated she fell out of her wheelchair on 5/13/15, because she appeared to be tired and her plan of care indicated the staff was to observe her for tiredness and lay her down if tiredness was observed and the plan of care was not followed. She indicated the fall on 5/15/15, was due to an unassisted transfer and the resident was capable of getting her wheelchair ready and transferring herself into her bed. She indicated the staff did not want her to do this, but she had unassisted transfers when staff could not catch her in time. She indicated she had skin tears from falls, but when she fell face forward was the first fall she had suffered a significant injury. During an interview on 5/28/15 at 9:23 a.m., CNA #21 indicated she received the information regarding her residents' care on her Resident Care Information Sheet. She indicated if she needed to know the bed height for a resident she would look at her Resident Information Sheet to get that information. At that time, she looked at the Resident Information Sheet for residents #12 and indicated she could not find a safe transfer height listed on the sheet for these residents, so she would leave their beds in the lowest position the bed could be in. 3. On 5/22/15 at 11:21 a.m., Resident #48 was laying in a full size low bed with one mattress laying next to her bed. On 5/26/15 at 11:23 a.m., the resident was laying in her full size low bed with her one mattress on the floor laying next to her bed. On 5/26/15 at 3:16 p.m., the resident was laying in the full size low bed with a mat next to her bed, but no mattresses were next to her bed. A current Resident Information Sheet provided by LPN #1 on 5/26/15 at 11 a.m., indicated the resident was extensive assist with two person physical assist for transfers and mobility, was to have two mattresses on the floor and she was a fall risk. The record for Resident #48 was reviewed on 5/22/15 at 4:27 p.m. [DIAGNOSES REDACTED]. The resident's progress notes indicated the following regarding her falls. 3/27/15 at 1:04 a.m., indicated the resident was found on the floor at her bedside on the mat on the floor, laying on her right side with her head facing the foot of the bed. 3/31/15 at 12;24 p.m., indicated IDT review for fall . Unwitnessed fall occurred on 3/27/15 at approximately 1210 am. Resident found lying on her back on the bedside mat with knees drawn up, rocking back and forth (normal position for resident) . Staff report that resident repositions self frequently while in bed often found with head at the foot of the bed. Root cause of the fall identified as Frequent repositioning in twin size bed. Does not allow much wiggle room. Interventions: SS (Social Services) referral-asst (assist) w (with) / obtaining consent from family for a full size bed or bariatric size bed or trial full body pillow for comfort with positioning. Sleep diary x 3 days. Trial administering APAP (Tylenol) at HS (bedtime) x (times) 14 days to rule out the frequent repositioning r/t (related/to) discomfort. Family agreed to trial bariatric size mattress flush against the wall w/mattress @ (at) BS (bedside) for 2-3 weeks. Implement 15 min (minute) checks while in bed to observe for frequent repositioning, ensuring resident is in the center of the bed, try to allow Resident to awaken naturally in the am, instead of morning nap-trial activities (encourage walks, social gatherings, show and tell with personal pictures, music low stimulating areas if appears overstimulated.) continue w/afternoon nap between 2p-4p (approx 1 hour in length), HS around 9 pm or if resident exhibits signs of tiredness/lethargy Trial nightime briefs. 4/23/15 at 7:21 a.m., indicated the resident was found on the mattress next to her bed with a blanket on her and she appeared to be asleep. 4/28/15 at 10:49 a.m., indicated IDT fall review .Unwitnessed fall occurred on 4/23/15 at approximately 630 am. Resident was found on the mattress at bedside w/blanket over her, sleeping . Root cause identified as restless sleeper, very mobile in bed. Interventions: mattress x 2 at bedside. Central supply referral to research vendors for a bed with a lower frame. Therapy referral recommendations for body pillow to aid w/comfort and positioning while in bed. During an interview on 5/26/15 at 3:19 p.m., CNA #25 indicated since Resident #48 had her bigger bed she did not need the two mattresses stacked next to her bed. She indicated she placed the gray flat mat next to her bed now like she used to do when the resident had the low bed before. During an interview on 5/26/15 at 3:36 p.m., LPN #1 looked at a Resident Care Sheet and indicated at that time, this resident was to have two mattresses stacked next to her bed. At that time, she went into the resident's room and informed CNA #25 the resident was to have two mattresses stacked next to her bed and she was to use her resident care sheet to provide care for her residents. During an interview on 5/27/15 at 3:24 p.m., LPN #1 indicated the correct height of the bed for transfers for Residents #71 and #12 depended on each resident according to how tall they were. She indicated each resident was a different height, so when they stood up out of bed their low beds would need to be raised off the ground at a different height, but she was unable to indicate what height each of these residents beds were to be raised to off the floor. During an interview on 5/28/15 at 9:23 a.m., CNA #21 indicated she received the information regarding her residents' care on her Resident Care Information Sheet. She indicated if she needed to know the bed height for a resident she would look at her Resident Information Sheet to get that information. At that time, she looked at the Resident Information Sheet for residents #48 and indicated she could not find a safe transfer height listed on the sheet for these residents, so she would leave their beds in the lowest position the bed could be in. A current policy undated, titled Fall Prevention and Management provided by the DON on 5/27/15 on 11:45 a.m., indicated Policy: It is the policy of (Name of facility) to ensure a safe environment with least restrictive measures while promoting the highest possible level of independence and quality of life . Admission: 8. CNA's will be made aware of residents at high risk for falls via CNA assignment sheet 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to provide interventions to maintain hydration for 2 of 3 residents reviewed for hydration. (Residents #39). This deficient practice resulted in Resident #39 being hospitalized with a [DIAGNOSES REDACTED]. Findings include: 1. On 5/27/15 at 10:56 a.m., the record review for Resident #39 was completed. [DIAGNOSES REDACTED]. The estimated amount of fluids the resident should receive daily are 2,280 milliliters of fluid a day. The lab values for the residents Creatinine and BUN (Blood Urea Nitrogen) as of 2/5/15, were at the high end of the normal value range. On 2/9/15, the resident's BUN level was 35 (range 7-25 mg/dL (milligrams/decaliter)) and Creatinine level was 1.5 (range 0.6-1.3 mg/dL). The Consumption Records dated February and March 2015, indicated the resident received less than 1500 milliliters of fluid daily. The Consumption Records indicated the following: 3/1/15- 840 milliliters of fluid were consumed 3/2/15- 1,060 milliliters of fluid were consumed 3/3/15-1,440 milliliters of fluid were consumed 3/4/15- 720 milliliters of fluid were consumed 3/5/15- 1080 milliliters of fluid were consumed 3/6/15- 840 milliliters of fluid were consumed 3/7/15-240 milliliters of fluid were consumed 3/8/15-840 milliliters of fluid were consumed 3/9/15-1080 milliliters of fluid were consumed 3/10/15- 240 milliliters of fluid were consumed The Elimination Record indicated the following: February 2015, the resident had from 1-3 softly formed or loose stools daily ranging from small to extra large. 3/1/15 through 3/4/15 (4 days)- there was no elimination documentation recorded. 3/5/15- Extra Large Loose bowel movement and a medium soft formed bowel movement. 3/6/15- Extra Large softly formed x 2, one Extra large loose and one small loose stool. 3/7/15- Extra Large soft formed stool 3/8/15- One medium loose stool. One Extra large and one large softly formed stool. 3/9/15- Extra Large softly formed stool. 3/10/15- One medium softly formed stool and one extra large and one large loose stool. The nurses notes for February and March 2015 had no documentation regarding notification of physician regarding the frequency of loose stools. The resident had an episode of unresponsiveness on 3/11/15 which resulted in her being sent to the hospital. The resident was sent to the hospital on [DATE], and the discharge summary indicated, .Discharge [DIAGNOSES REDACTED]. 2. Syncopal episode. The patient hardly arousable, patient quite dehydrated. 3. Dehydration 4. Diarrhea, no stools since she has been here in the hospital .5. Acute kidney injury, Creatinine 1.6, now down to 1.1 .8. Dementia .Observation Summary: who was in her normal state of brain function before lunch yesterday when her grandson came back about 45 minutes later and found that she was not easily resposible(sic) . She was seen by a provider at (name of facility) who told the grandson that he saw no focal neuro findings, The patient had no focal neuro findings when she came here, but was found to be quite dehydrated . patient felt much better with fluid hydration and had no further syncopal episode On 5/28/15 at 12:39 p.m., the Director of Nursing (DON) was requested to provide any hydration interventions, any other physician orders [REDACTED]. As of the exit conference on 5/28/15 at 5:40 p.m., she indicated she had provided all the documentation she had for the resident. 2. On 5/26/15 at 12:21 p.m., two different unidentified CNA's gave different answers for how many milliliters were in the different kinds of glasses observed in the dining room. There were tall skinny glasses, short fat glasses, short thin glasses, and coffee mugs observed on residents' trays in the dining room. On 05/28/15 at 9:47 a.m., CNA #26 indicated the CNA's document the monthly nutrition values for food and drinks in the Meal Consumption record book. She indicated they write how much was consumed at meals. She indicated in the residents' rooms they have 120 milliliter plastic cups and larger 240 milliliter plastic cups. She had to confirm with LPN #22 regarding the milliliters of the glasses. Also, CNA #26 talked to another unidentified CNA and the two of them indicated the newer glasses on the table were 200 milliliters and the other unidentified CNA indicated they were 210 milliliters. 3.1-46(b)

Based on observation, interview and record review, the facility failed to ensure the safety of confused and dependent residents, in that when resident's were dependent upon staff for supervision and determined to have a cognitive impairment, the nursing staff failed to ensure residents received adequate supervision to prevent accidents which resulted in severe lacerations, abrasions and bruising for 5 of 5 sampled and 4 of 13 supplemental sampled resident's reviewed for lack of supervision which resulted in injury. (Resident's "A", "B", "C", "D", "E", "L", "Q", "R" and "S"). In addition the facility failed to implement their policy in which residents who were identified as a fall risk were monitored through specific signage for 10 of 10 supplemental sampled residents. (Resident's "G", "H", "I", "J", "K", "L", "M", "N", "O", "P"). Findings include: 1. The record for Resident "A" was reviewed on 01-23-13 at 1:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's "Fall Risk Assessment," dated 03-08-12 indicated the resident was at "high risk for falls," with a total score of "10." A notation on this risk assessment, indicated a score of 10 or greater identified the resident at "High Risk" for falls. Review of the resident's MDS (Minimum Data Set), Annual assessment dated [DATE], and Quarterly assessment dated [DATE], indicated the resident had "severe cognitive impairment, was not able to balance self without staff assistance in moving from a seated to standing position, walking, turning around, moving on or off toilet, and surface to surface transfer." In addition the resident was assessed with [REDACTED]." The resident's current plan of care, originally dated 06-06-12, indicated the resident had "poor memory recall abilities with impaired decision making skills and poor safety awareness." A subsequent plan of care, noted as "active through 02-15-13," indicated, "I am able to bear weight but I become unsteady during transfers and ambulation and need staff support. My safety awareness is poor because of my impaired judgement and I will need cues and reminders throughout each shift. I am at risk for an injury if I fall because I have osteoarthritis." The "goal" to this plan of care indicated, "I do not want to have a fall with injury through the next review." Nurses note, dated 08-24-12, at 11:48 p.m., indicated, "Resident was found in t.v. (television) room during activity at approximately 1600 (4:00 p.m.), lying face down on the floor in front of wheel chair. Res. (resident) was crying and noted large hematoma on left forehead. Area was not actively bleeding but had already started to bruise. Res. is unaware of how (resident) fell . Res. was alert to self as per usual self ice placed on forehead and assisted resident back into chair. (Name of physician) was in building and looked at res. for nurse and she (in reference to the physician) felt that res. needed X-ray of head because she could feel an area that was indented." Nurses note, dated 08-25-12 at 1:46 a.m., indicated, "Lg. (large) raised/bruised area noted L (left) forehead; area abraided. Very painful to touch, esp. (especially) the indented area." The resident received an Occupational Therapy Evaluation, dated 09-25-12, and a Physical Therapy Evaluation, dated 09-26-12, in which both disciplines indicated the resident was "Fall Risk." The resident's plan of care lacked a current intervention in regard to the resident being "found" by the nursing staff, left unattended, in the activity room. The 11-07-12 "Nursing Evaluation," indicated the resident had "chronic confusion, altered perception, "no falls in the past 3 months," uses a personal alarm, and had a "fall risk score" of "14." Review of the Reportable to ISDH, with a dated incident of 01-9-13, indicated the resident "fell out of chair - reaching for an item. Unwitnessed fall. Resident in W/C (wheel chair) in dining room. Attempted to get up on own, fell forward out of W/C and hit forehead on floor. 3.0 centimeter skin tear to left lower forearm and 2 lacerations (6 centimeters and 3 centimeters) to forehead." The facility "Event Report, dated 01-09-13, indicated, "Resident in dining room, no staff present." The resident was transported to the local hospital emergency room , where the resident received treatment. A Medical Imaging report, dated 01-09-13, with a CT (Cat Scan) of Brain/Head indicated: trauma, scalp injury - reconstruction was performed." A physician progress notes [REDACTED]. (patient) sent to ED (Emergency Department) on 01-09-(13) after fall. Sitting at dinner, fell and hit head on edge of table. (Resident) required 2 deep absorbable sutures along with 6 additional sutures. Due to skin fragility it was difficult)to approximate well. Steri strips applied as well. Per nurse, no bleeding issues and pt. (patient) has has been fine not requiring additional pain meds besides those already scheduled prior to incident. Approximate 8 cm (centimeter) laceration across forehead with another 3 cm. extension off the left lateral end. Steristrips in place. Old, dry blood. Poorly approximated." A subsequent physician progress notes [REDACTED]. "F/U (follow up) on above. Per nursing area to forehead is healing. Nursing reports no change in mental states, appetite or mood. I spoke to DON (Director of Nurses) about the fall and she states pt. was in wheel chair in dining room facing away from the table. One therapist in the dining room at time of fall but did not witness. Therapist turned to assist another resident and heard fall, turned around to find (name of resident) on the floor, there was no table between pt's w/c and where (resident) fell . It is assumed that (resident) struck head on floor only and nothing else in the line of the fall. Pt. also reportedly c/o(complained of) knee pain since fall, has h/o (history of) OA((osteoarthritis)." After the resident sustained [REDACTED]. The record lacked intervention to alert the staff of unassisted transfer or attempted ambulation. Observation on 01-23-13 at 10:00 a.m., the resident was seated in a wheel chair. The resident's left forehead had a bandaged dressing over a raised area. Beneath bilateral eyes was resolving bruising which was gray/yellow in color. Observation on 01-23-13 at 12:15 p.m., 01-24-13 at 12:30 p.m. and 01-28-13 at 12:10 p.m., the resident did not have a personal alarm. Interview on 01-23-13 at 12:00 p.m., the Unit Manager Licensed Practical Nurse employee #5 indicated the resident "didn't use an alarm or sensor pad" to alert the staff of unassisted ambulation or transfer. Interview with a concerned family member on 01-24-13 at 8:15 a.m., indicated a "worry" that (name of resident) could "fall and have a head injury in August" and the facility didn't "put anything in place, and didn't even provide enough supervision to get to (resident) before the this last fall." 2. The record for Resident "B" was reviewed on 01-24-13 at 11:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility for Rehabilitation Therapy Services. A "Fall Risk Assessment," dated 09-20-12, indicated the resident was "alert with acute confusion and oriented to person" and "not" a fall risk. The MDS, dated [DATE], indicated the resident was cognitively alert, but had problems with balance in which the resident needed the assistance of the staff to rebalance in regard to moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfers. In addition, the assessment indicated the resident required extensive assistance with transfer, bed mobility, and toileting and one staff member. Review of the Nurses notes, dated 11-06-12 at 4:19 a.m., indicated, "At 0200 (2:00 a.m.) res. was transferring with assist times 1 to get up to the bathroom. During transfer, resident said "felt weak and could not stand," so along with the aid (CNA Certified Nurses Aide), slowly lowered self to the floor." A Nurses note, dated 11-20-12 at 2:00 p.m. indicated, "Res. found on BR (bathroom) floor per writer. BR call lt. (light) going off. Back of W/C to front of sink. Left side of chair brake not locked. Res. laying on floor tilted to right side. Res. stated hit right side of head and right hip. No bruising or swelling noted to these areas. States was transferring self from commode to chair. 'My legs gave out.'" Nurses note, dated 12-08-12 at 1:42 p.m., indicated, the "Resident tearful this AM," and expressed "I am just so confused. When writer oriented res, res, stated 'I know why I'm here.'" Nurses note, dated 12-11-12 at 10:05 a.m., indicated, "found on the floor face down at 9:35 a.m. No change with LOC (level of consciousness), with multiple skin tear (sic) right knee 9 cm (centimeters) by 4 cm, Left knee 3 cm, L knee 1 cm by 1 cm, above right eye 6 cm by 4 cm, on right chick (sic) 5 cm by 2 cm, right shoulder 4 cm by 4 cm. Pressure dressing forced on forehead (sic), knee and sholder (sic). Res. to ER (emergency room ) for treatment and eval. (evaluation)." The hospital "wound/skin evaluation," dated 12-11-12, assessed the resident's injuries as follows: "#1 - right forehead - partial flap with sutures just above eyebrow - 4 cm by 2.4 cm with ecchymosis." "#2 - right cheek 3 cm by 2.2 cm - skin tear." "# 5 - skin tear 7 cm." "#6 right knee distal 6.5 cm by 4 cm - skin tear." Review of the hospital discharge summary, dated 12-12-12, indicated the resident was admitted to the hospital "after falling at the skilled nursing facility. The patient fell and hit head and also had some wounds to right knee, left knee and right eye periorbital and forehead. The patient is stable and is hesitant to return back to the skilled nursing facility due to this fall." The "Fall Risk Assessment," dated 12-12-12, indicated the resident was now alert and oriented to person and "not" at risk for falls. 3. The record for Resident "C" was reviewed on 01-23-13 at 1:50 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The nursing admission evaluation dated 10-18-12 indicated the resident had no behavior problems, no cognitive impairment with modified independence, no confusion but did exhibit impaired safety awareness. The "Fall Risk" score was "4" and not considered a "fall risk." Review of the current plan of care dated 10-26-12, indicated the resident was "at risk for falling due to impaired balance and new surroundings" and "experiencing some periods of acute confusion and can be resistant to caregivers at times." Review of the "Skilled/Non-Skilled Nursing Clinical Review," dated 10-21-12 indicated the resident was "alert and oriented to person, place and time, no behaviors noted, cooperative, gait unsteady." The "Skilled/Non-Skilled Clinical Review," dated 10-23-12, indicated the resident displayed a "continued unsteady gait," but now included "weakness - bilateral." A subsequent MDS assessment, dated 11-07-12, indicated the resident displayed memory problems and moderate cognitive impairment. The "Skilled/Non-Skilled Clinical Review," dated 11-09-12, assessed the resident as "decreased social activities, cooperative but withdrawn, decreased grasp - left and right," and a subsequent clinical review, dated 11-11-12, the resident's cognitive status had declined and was "alert" but only "oriented to person - dwells on illness/other problems, weakness - bilateral weakness - unilateral." The "Skilled/Non-Skilled Clinical Review," dated 11-12-12, indicated the resident was now "lethargic." Review of the plan of care dated, 11-13-12, indicated "I am at risk for falling due to impaired balance and new surroundings." Interventions included "provide limited assistance with transfers as needed, assist to wear non slick footwear that fits, instruct on safety measures to reduce the risk of falls, keep areas free of obstruction to reduce the risk of falls or injury, keep nurse call light within easy reach. Instruct to use call bell or call out for assistance." A subsequent plan of care, noted as "current through 02-28-13," indicated the resident was "experiencing some periods of acute confusion and can be resistant to care givers. This is not my usual personality. I am also experiencing some cognition decline and also have very poor hearing which causes me to not understand caregivers at times." A physician order [REDACTED]." An 11-24-12, Hospice nursing note documented a "phone call to (family member) and discussed concerns. One concern was pt. being taken to bathroom by staff. (Family member) feels pt is too weak to safely ambulate by self and (resident) does not remember to use call light. Talked to (name of facility licensed nurse) who agrees and has instructed CNA's to toilet pt q (every) 2 hours and to encourage daily baths." Review of the resident "Clinical Notes Report," were as follows: 11-24-12 and 11-25-12, identified a change in the resident's cognitive abilities, with "delusions/hallucinations" prior to the beginning of Hospice services and ongoing notation of family concerns related to the resident's safety. "11-24-12 2:48 p.m. Appetite poor. Res. up to BR (bathroom) per self. At times, res. removes O2 (oxygen) to go to BR at times. Res. talking out at times and reaches into air with arms. (Family member) reports res. more confused this afternoon. Res. spoke of little children in the room." "11-25-12 at 2:30 p.m. Res. alert to name and place. Intermittently has periods of lucidity and confusion/delusions. 'Get me out of the fire ! ... Cut this !' Res. clutching O2 nasal cannula before neck. Assisted res. to dress in 'day clothes'. 'I don't know why I have to get dressed. My pajamas are warm.' Res. wearing two shirts and then covered with light blanket per request. Family expressing concern regarding res." "11-25-12 at 7:01 p.m., Resident was lethargic before evening shift stated, sitting in the w/c. Family in to visit around 2:30 p.m. Put resident in bed. Family had concerned (sic) why resident is so lethargic ? According to report from previous shift nurse, resident up all night. Family was very anxious and request to call the hospice nurse. Writer told resident to eat dinner, res. said, 'I want cereal,' writer reasure (sic), this is dinner time. Res. again said 'I want cereal,' so one of the CNA (sic) brought cereal. After awhile nurse went to check either (sic) resident ate meal or not. Resident lying on the bed and naphking (sic) is on the plate. Writer ask (sic), did you eat meal {name of resident) ? Resident said, 'you put poison in meal, shut up and go out right now.' Resident looks very agitated." "12-01-12 at 7:00 a.m. Resident fell at 3:45 a.m. witnessed by nurse. Resident scraped the bridge of nose on the bedside table sustaining a skin tear with small amt. (amount) of bleeding. Has been slightly restless. Refuses to use call light which is in reach to request assist from staff. Resident assisted to the bathroom by nurse and gait was very unsteady. First Aid applied to bridge of nose, cleansed with NS (normal saline) and steristrips applied after bleeding stopped." The 12-01-12 notation, indicated that at 7:45 a.m., the resident had steri strips applied to the nose and also now was assessed with [REDACTED]." During interview on 01-24-13 at 1:00 p.m., the Director of Nurses indicated when the resident was started on Hospice due to a significant change in condition an assessment was to be completed. When requested to review of the Significant Change MDS and the "Fall Risk evaluation/assessment" associated with the Significant Change in Condition, the Director of Nurses indicated "I won't lie to you I can't find one." When further interviewed what the facility put in place after the family member expressed concerns on 11-24-12, and as the resident's condition continued to decline, the Director of Nurses indicated she couldn't "find anything." 4. The record for Resident "D" was reviewed on 01-23-13 at 12:40 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident had been admitted to the facility from a secured dementia unit. Review of the resident's MDS, dated [DATE], indicated the resident had severe cognitive impairment, with both short term and long term memory loss and also indicated the resident was not able to balance self without staff assistance in moving from a seated to standing position, walking, turning around, moving on or off toilet, and surface to surface transfer. Review of the resident's plan of current, noted as "current through 02-15-13," indicated, "I am at risk for a fall with injury due to my impaired safety, awareness. I attempt ambulation and transfer unassisted." Interventions to this plan of care included "sensor pad to W/C at all times." A "Fall Risk" assessment dated [DATE], indicated the resident was at High Risk for falls with a total score of "16." Review of the current Resident Care Information sheet on 01-23-13 at 11:30 a.m., indicated the resident had a "sensor pad" not only to wheelchair but also to "low bed." A physician order [REDACTED]." Nurses Notes indicated the resident had been found on the floor/identified with a falls on 12-28-11, 12-30-11, 01-01-12, 01-25-12, 01-26-12, 01-28-12, 02-03-12, 02-13-12, 03-11-12, 03-15-12, 11-10-12, 12-31-12 and 01-24-13. The Nurses notes, dated 01-16-12 indicated IDT (interdisciplinary; team) review of falls. "Fall on 12-28-11, 12-30-11 and 01-01-12. Staff education - sensor pad to w/c." "01-25-12 12:00 a.m. - Found resident sitting up on floor in room. neurochecks initiated." "01-28-12 11:30 - Resident found on floor in room by w/c. Res. attempting to get in bed at the time. Unwitnessed." "02-03-12 9:40 a.m. Resident attempted to transfer self from w/c. W/C at foot of bed. Unable to ambulate - fell on to floor." "02-06-12 10:30 p.m. IDT review for falls. Fall 01-26-12 and 01-28-12 at 12:00 a.m. on 01-26-12 - found scooting on floor. Therapy screen on 01-25-12 at 11:30 a.m. Found on floor - sensor pad on w/c when available." "02-13-12 11:30 p.m. - Res. observed in hallway on buttocks scooting using hands. Stated 'I need to go to Chicago to play the piano for the wedding at midnight.' Attempted to re-orient res. to time of day and weather conditions. Res. stated 'I'll take the train.'" "02-21-12 2:00 p.m. IDT review for falls. fell on [DATE]. Self transfer from W/C." "03-11-12 4:45 p.m. Found supine on floor room (number documented). W/C behind resident." "03-15-12 10:00 p.m. Res. had fall at 4:15 p.m. Res. was in activity room in W/C No staff witnessed fall, but found res. lying on back next to W/C." "03-20-12 10:00 a.m. IDT review for falls. Fall on 03-11-12 and 03-15-12. Found in another res. room on 03-11-12 at 6:00 p.m. CP (care plan) not followed. On 03-15-12 attempted self transfer. Sensor pad added to W/C." "12-31-12 at 3:00 p.m. - Found on the floor by Restorative Aide with head up against the wheel chair. Minimal bleeding to the right (back) side of resident head scalp area. Physical assessment completed and a small laceration noted to right side (back) of head/scalp. Area cleaned and triple antibiotic ointment applied to area." "01-24-13 at 3:05 p.m. - Res. on floor from low bed to mat at side scooting on floor. assisted back to bed and no injury noted and no s/s (signs or symptoms of) pain or discomforts (sic)." The current Fall Risk Evaluation, dated 01-24-13 indicated the resident had falls in the past 3 months and the score was "12." Observation on 01-23-12 at 12:30 p.m., the resident was seated in the wheel chair in the dining room. The resident attempted to stand independently. The nursing staff redirected the resident, and assisted the resident into the wheelchair. The personal alarm did not sound at the time the resident attempted to stand. Observation on 01-24-13 at 12:10 p.m., the resident was seated in the wheel chair in the dining room. The resident attempted to stand upright from the wheel chair. The sensor alarm did not sound. When interviewed on 01-24-13 at 12:15 p.m., CNA employee #11 indicated the resident did not have the sensor pad on the chair. "(Name of resident) is suppose to have it on." Further interview on 01-24-13 at 12:30 p.m., the Unit Manager Licensed Nurse employee #5 verified the resident did not have the sensor attached to the wheel chair. The record indicated the resident fell or was found on the floor on 13 occasions. On one occasion (12-31-12) the resident sustained [REDACTED]. Even though the IDT recommended the use of a sensor pad, the resident remained without the device to alert the nursing staff, and during observation, the resident did not have the device attached to the W/C to alert the staff of unassisted ambulation or transfer. 5. The record for Resident "E" was reviewed on 01-24-13 at 12:15 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident had a previous fall on 04-20-12, in which the resident sustained [REDACTED]. The IDT (interdisciplinary team) Post Fall Assessment, undated, indicated "Resident stood up from chair in DR (dining room). fell on to lt. (left) side. ST (skin tear) to left elbow. Yelling out and guarding right hip - x-ray obtained - hip fracture." "Contributing factors - rises unassisted, forgets to use call light, misuse/lack of adaptive device, unsteady gait, cognitive decline." The resident was transferred to a local area hospital for evaluation and treatment. Review of the Fall Risk Assessment, dated 04-24-12, and the most recent assessment, dated 01-17-13, indicated the resident was at "High Risk" for falls with a score of "18." The MDS assessment , dated 12-27-12, indicated the resident had both short term and long term memory loss with a cognitive score which indicated the resident had severe cognitive impairment. The resident was also assessed with [REDACTED]. The plan of care, noted as "current through 04-04-13," indicated "I am at risk for fall with injury due to my impaired balance/coordination, poor safety awareness, history of falls...." Interventions to this plan of care included "keep floors in room/hallways clean, dry and free of clutter/obstacles that may impede safety while ambulating or in W/C, keep frequently use personal items within reach and in same familiar location, keep bed in low position with mat next to bed while in bed, provide toileting if restless, rolling our of bed or found on mat next to bed, staff education regarding following plan of care, perimeter mattress on bed, staff education on responding to alarm." Further review of subsequent IDT Post Fall Assessments, indicated the following: "05-04-12 Found lying on floor on back in room (number documented) - abrasion to lower back, recent fracture - no safety recall." "05-21-12 3:50 a.m. Trying to get up out of bed. Assisted to floor. Bed in low position. No injury. No safety recall. Offer snack - dress appropriately if continues to try and get oob (out of bed)." "05-26-12 4:06 p.m. Found sitting on floor in activity room. Attempted to transfer to another chair. No injury. CP (care plan) reviewed. Alarm not functioning. Batteries replaced." "05-30-12 2:45 a.m. Responded to bed alarm - found resident sitting on floor with back against bed. No apparent injury. Contributing factors - need to void. Care plan not followed as written - last toileted at 1:31 p.m. Staff education." Additional incidents as documented in the nurses notes included the following events: "09-16-12 3:32 p.m. Found in Activity Room with W/C turned upside down and alarm sounding off." "09-19-12 Found on floor next to bed in up right position." "10-14-12 2:50 p.m. Resident roommate family member alerted staff resident was climbing out of bed. Found on floor (on mat) seated position. No injury - alarm not sounding. CNA said alarm was on but not working. CNA educated to personal alarms." "11-14-12 8:33 a.m. Resident in DR and alarm sounding - unable to get to resident in time and resident went to floor on buttock. Alarm sounding and staff education on chair alarms." 12-18-12 10:46 p.m. Resident stood up unassisted from W/C while nurse was in another resident room. Resident was in the hallway lying on back to the right side of the W/C and found by another staff member." "12-29-12 11:00 a.m. Found sitting on mat next to bed with alarm going off. Had alarm in hand looking at it. No injury." "01-17-13 2:40 p.m. While in DR W/C was unlocked and chair alarm was on and nurse was standing next to kitchen window. Alarm sounded off as (resident) was standing straight up holding onto W/C. I had ahold of (resident) when legs gave out and left side leaned against my body. Found skin tear to left shoulder 4 cm by 2.5 cm." 6. The record for Resident "Q" was reviewed on 01-28-13 at 12:25 p.m. [DIAGNOSES REDACTED]. deep vein thrombosis and vertigo. These [DIAGNOSES REDACTED]. A notation prior to the resident's admission to the facility, indicated the resident was a "fall risk" although this risk was not identified at the time of admission. Review of the admission "Fall Risk Assessment," dated 01-11-13, indicated the resident had "short term and long term memory loss, moderate cognitive impairment and poor decisions making skills. Cues and supervision required." The 01-23-13, MDS assessment indicated the resident had severe cognitive impairment. Review of the IDT notes, dated 01-25-13 at 5:35 a.m. indicated the resident was lying on floor next to bed with head next to side rail. The resident "attempted to self transfer and had decreased safety awareness, rises unassisted, forgets to use call light, had an unsteady gait. No injury." The nursing staff implemented the use of a low bed with a mat adjacent to bed and removal of the side rail. An additional fall note on 01-27-13 at 6:45 a.m. indicated the resident was "found on floor next to bed on back. Unable to state events - off mat on right side." A new intervention included "removal of the low air loss mattress and add perimeter mattress to bed." The nurses notes indicated this fall resulted in an injury of an abrasion to the right knee which measured 5.4 cm by 1.2 cm. Although the first event resulted in no injury the resident was incorrectly assessed for "Fall Risk" at the time of admission with a total score of "8." 7. The record for Resident "R" was reviewed on 01-28-13 at 12:50 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The Fall Risk Assessment, dated 09-05-12 indicated a score of "10," high risk for falls. The resident's MDS assessment, dated 11-21-12, indicated the resident had severe cognitive impairment and required extensive assistance with transfer and bed mobility. The Resident Summary, dated 11-22-12, also indicated the resident was "High Risk" for falls. The current plan of care indicated "I am at risk for fall with injury due to my osteoporosis, and history of compression fracture. I have dementia and delusion...." Interventions to this plan of care included "do not leave in room alone when in wheelchair." The IDT notations, dated 05-04-12 indicated the resident was "found laying on floor on back in TV/activity room - abrasion to back. Dependent for transfers." A nurses note dated 12-25-12 at 4:19 p.m. indicated the "Resident was found sitting on floor in front of W/C by family member that came and alerted staff." Observation on 01-28-13 at 12:20 p.m., the nursing staff transported the resident from the dining room and into the TV room. The resident was left unattended. The Resident Care Information Sheet lacked direction for the nursing staff not to leave the resident unattended while seated in the wheelchair. 8. The record for Resident "S" was reviewed on 01-28-13 at 8:55 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the hospital Discharge physician orders [REDACTED]." The admission nursing evaluation dated 11-07-12, indicated the resident had "acute confusion, oriented to person, memory problems a history of a head injury and impaired balance." The "Fall Risk" score was "9" which indicated the resident was not at a high risk for a fall. Review of the MDS assessment, dated 11-19-12, indicated the resident had moderate cognitive impairment, required extensive assistance with bed mobility, transfer, hygiene and toileting. In addition the assessment indicated the resident was only able to "rebalance self with the assistance of staff in regard to moving from seated to standing position, one and off toilet and surface to surface transfer." The admission plan of care indicated, "I am at risk for falling due to left sided weakness with impaired balance, history of falling and new surrounding." Interventions to this plan of care included, non skid footwear, extensive assistance with transfer and 2 staff members, frequent reminders." Additional interventions, dated 11-23-12 included a low bed, mats on floor and a scoop mattress. On 12-07-12 the nursing staff provided the resident with a Dycem to the wheel chair. Review of the nurses notes indicated the resident fell or was found on the floor on the following occasions: "11-21-12 at 1:30 p.m. Balance problem while sitting - found beside bed." "11-23-12 10:24 a.m. Had been toileted and assisted to bed after lunch. Per Social Service resident up with confusion noted when fatigued. Unable to express need. Perimeter matt to be added with 2 mats on floor." "11-25-12 at 5:00 a.m. Found sitting up right beside the bed. Failure to care plan for risk factors - poor safety judgement." "12-04-12 3:15 p.m. Found on floor sitting position folding clothes - incontinent of bowel." "12-06-12 7:45 a.m. Found sitting on floor in front of wheelchair. States hit head. No s/s of redness or swelling noted to head. Failure to care plan for risk factors, unknown balance problems while standing. Care plan revision: poor safety judgement." "12-0