**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision to prevent a fall for one resident (Resident 1) of two sampled residents when Certified Nursing Assistant B (CNA B) left Resident 1 on the toilet unsupervised then left Resident 1 ' s room to attend to another resident. This failure resulted in Resident 1 sustaining a fracture (a complete or partial break of the bone) of the right distal fibula (smaller long bone of the lower leg) and the right distal tibia (larger long bone of the lower leg). Findings: A review of Resident 1 ' s admission record indicated she was admitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness and paralysis of the body) affecting the left dominant side, epilepsy (a nerve disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden temporary bursts of electrical activity in the brain that can cause changes in body movement, function, or awareness]), and memory deficit following a cerebral infarction (a stroke caused by disrupted blood flow to the brain). A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/13/24, indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or assistance touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for toilet transfers. The MDS further stated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports limbs, but does half the effort) for toileting hygiene (the ability to maintain perineal [genital and anal area] hygiene, adjust clothes before and after voiding [emptying the bladder] or having a bowel movement). A Fall Risk Care Plan, initiated 8/1/23 indicated Resident 1 was at high risk for falls related to confusion, deconditioning (a decline in the physical functioning of the body), gait (a person ' s manner of walking)/balance problems, urinary urgency and incontinence (inability to control the flow of urine from the bladder), poor communication/comprehension, psychoactive drug use (drugs which affect mental processes), unaware of safety needs, desire to be independent with ongoing overestimation of actual abilities, severe bilateral lower extremity (both right and left legs and feet) neuropathy (weakness, numbness, and pain from nerve damage), history of many falls here, at home, and at previous Skilled Nursing Facility. Fall Risk Assessments, dated 7/30/24, 9/4/24, 9/21/24 and 11/17/24 all indicated Resident 1 was a high risk for falls. Resident 1 ' s progress notes between 8/1/24 and 11/30/24 indicated Resident 1 had 4 falls, 3 of which were unwitnessed. An Interdisciplinary Team (IDT, a group of people with different areas of expertise who work together to ensure care) Progress note dated 8/1/24 indicated the Root Cause of Resident 1 ' s fall was, Slipped, and fell to the floor – plus resident has a history of frequent falls. Resident has neuro cognitive deficits [a decline in mental function that is caused by a medical condition] - legs have neuropathy – decreased safety awareness. Resident is very forgetful. Resident has poor judgement. A review of written statement dated 11/17/24 from CNA B about his account of Resident 1 ' s fall indicated, .assisted [Resident 1] by wheelchair to restroom on 11/16/24 around 2235 [11:35 p.m.]. Once [Resident 1] was positioned on the toilet I removed her wheelchair out of restroom to prevent her to attempt to transfer on her own. Before leaving [Resident 1] I reminded her to use call light in restroom when she was finished. While waiting on her I went to assist another resident. On coming back [CNA C] and I heard a resident in room [ROOM NUMBER]B asking for a blanket. While [CNA C] was in room [ROOM NUMBER]B she heard a knock on the wall. On investigating she found [Resident 1] on restroom floor. I proceeded to get charge nurse. A Progress Note, dated 11/17/24 at 00:30 indicated, .this writer called to resident ' s bathroom. Upon arriving, resident was found lying on the floor in the bathroom. Upon assessing resident .there was an obvious ankle injury with severe pain .[Physician] called, informed of situation. Orders received to send to ER [Emergency Room] for evaluation . A discharge summary from the hospital dated 11/17/24, indicated Resident 1 was diagnosed with a closed fracture of the right ankle. Resident 1 was discharged back to the facility with a splint (a medical device that immobilizes the ankle joint to help with healing)on the right ankle, pain medications, and instructions to follow up with an Orthopedic Physician (a medical professional who diagnoses and treats conditions of the bones, muscles, and joints). During an interview on 1/7/25 at 11:32 a.m., the Director of Nursing (DON) stated she was notified by staff Resident 1 had fallen after she requested privacy while on the toilet. The DON verified Resident 1 had a history of falls. The DON also stated the best practice was for staff to stay within eyesight, so residents did not try to transfer on their own and fall. The DON further stated CNA B could have provided privacy and still stayed in the room. During an interview on 1/7/25 at 1:43 p.m., Licensed Nurse D (LN D) stated Resident 1 required assistance and supervision in the bathroom as she was a fall risk. LN D stated Resident 1 had a history of noncompliance with using the call light. LN D further stated staff should stand by the bathroom door when a resident requested privacy; staff could not have supervised a resident if they left the room. During an interview on 1/7/25 at 2:15 p.m., the Director of Staff Development (DSD) stated best practice when toileting a resident who requests privacy was to be able to see the resident without them seeing you. The DSD further stated staff could not have provided supervision when they were out of the room. During a review of a facility policy titled, Fall Management Program, last revised 11/7/2016, the policy indicated, A resident who sustains multiple falls will be considered a high risk to fall and as a result may sustain a major injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to regularly provide showers for one out of two sampled residents (Resident 1). This failure was a contributing factor for: 1.staff not identifying Resident 1 wound on top of his right shoulder, 2. the wound on top of Resident 1's right shoulder to become infected (having an infection- invasion or growth of germs in the body) that later developed into sepsis (life threatening condition, a severe form of infection). Findings: A review of Resident 1's face sheet (demographics) indicated Resident 1 was admitted on [DATE] with a diagnoses of Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high) and Essential Hypertension (HTN, high blood pressure). Resident 1 had an additional diagnosis of Cellulitis (a deep bacterial infection of the skin) of upper limb when he came back from the hospital on 8/12/24. A review of Resident 1's Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 6/27/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1's MDS assessment also indicated he was dependent on staff during dressing, toileting, bathing or showering and putting on or taking off footwear. A review of shower sheet for 7/2024 indicated Resident 1 should have received a total of 9 showers. Based on the shower documentation, Resident 1 only received 2 bed baths (washing someone in bed) out of 9 showers on these dates: 7/13/24 and 7/31/24. There was no shower sheet provided for 8/2024 which indicated Resident 1 did not receive shower nor bed bath between 8/2/24 and 8/6/24. A review of Resident 1's hospital discharge note dated 8/12/24 indicated Resident 1 had a purulent (containing pus- a thick fluid containing dead tissue and bacteria, associated with infection) cellulitis with small superficial abscess of right superior shoulder and the sepsis was secondary to the cellulitis and small abscess of the right superior shoulder. During an interview on 8/15/24 at 1:10 p.m., Licensed Nurse D stated Resident 1 was scheduled to receive showers twice a week and more often as needed. LN D stated shower refusal should be documented. LN D stated when care was not documented, it meant the care was not provided. LN D stated not providing regular showers to residents could result in impaired skin, wound development and infection, low self-esteem, and bad odor. During an interview on 8/15/24 at 1:13 p.m., Certified Nursing Assistant (CNA) E stated residents were scheduled to receive showers at the facility twice a week and more often as needed. CNA E stated it was important for residents' well-being to receive showers as scheduled regularly. CNA E stated not providing showers to residents regularly as scheduled could lead to infection, development of wound or pressure ulcer (bed sores, injury to skin and underlying tissue resulting from prolonged pressure on the skin), worsening of wound or pressure ulcer or missed skin impairment. During an interview on 8/15/24 at 1:15 p.m., CNA F stated residents were scheduled to receive showers twice a week and more often as needed. CNA F stated not providing showers regularly as scheduled could result in wound to worsen, wound infection, sepsis, and missed skin impairment. During an interview on 8/15/24 at 1:21 p.m., LN B stated residents were scheduled to receive showers twice a week and more often as needed. LN B stated refusal should be documented. LN B stated not receiving showers regularly and as scheduled could lead to wound infection, development or worsening of wound or pressure ulcer. LN B stated residents would also have low self-esteem or they might feel uncomfortable. LN B stated if a resident was sent to the hospital and the diagnosis was sepsis, it meant resident already had an infection at the facility that was missed and was not treated with antibiotics (ABX, a type of antimicrobial substance active against bacteria). LN B stated sepsis was life threating and source could be from untreated Urinary Tract Infection (UTI, an illness in any part of the urinary tract, the system of organs that makes urine) or infected wound. During an interview on 8/15/24 at 1:35 p.m., LN G stated residents were scheduled to receive showers twice a week or more often as needed. LN G stated refusals should be documented. LN G stated if not documented, it meant showers or bed bath was not provided. LN G stated not providing showers or bed bath to residents regularly placed them at risk for staff to miss residents skin impairments, wound to become infected, development of sores or worsening of sores. LN G stated sepsis could be a result of untreated UTI or wound infection. During a concurrent interview and shower sheet record review on 8/15/24 at 1:50 p.m., the Assistant Director of Nursing (ADON) stated residents were scheduled to receive showers twice a week and more often as needed. The ADON stated residents should receive at least 8 to 9 showers in a month. The ADON verified Resident 1 was scheduled to receive showers on Mondays and Thursdays. The ADON verified the shower sheet for 7/2024 indicated Resident 1 should have received a total of 9 showers, but only received 2 bed baths out of 9 showers on these dates 7/13/24 and 7/30/24 . The ADON verified that from 8/2/24 up to 8/6/24, Resident 1 did not receive any showers or bed bath at all. The ADON stated if Resident 1 was refusing, staff were not documenting. The ADON stated staff should be documenting refusals. The ADON stated if it was not documented, it meant the care was not rendered. The ADON verified the shower documentation indicated Resident 1 was not receiving shower/bed bath regularly. The ADON stated not providing showers regularly and not assessing residents' skin thoroughly was a contributing factor on why Resident 1 's wound on top of his right shoulder was missed and why the wound on top of his right shoulder became infected. A review of the facility ' s policy and procedure (P&P) titled Skin and Wound Management, revised 1/1/12, the P&P indicated CNAs will complete body checks on residents ' shower days and report unusual findings . A review of the facility ' s policy and procedure (P&P) titled Showering and Bathing revised 1/1/2012, the P&P indicated observing the skin is performed during bathing. A review of the The Cleveland Clinic publication on skin care dated 4/27/2020 indicated Dr. Khetarpal says We come in contact with thousands of allergens every day. Showering rinses off those allergens, as well as bacteria and viruses. A review of the Healthline publication on skin care dated 1/29/2019 indicated Poor hygiene or infrequent showers can cause a buildup of dead skin cells, dirt, and sweat on your skin. Showering too little can also trigger an imbalance of good and bad bacteria on your skin and too much bad bacteria on your skin also puts you at risk for skin infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed: 1. to ensure skin assessments (process of examining entire skin for any abnormalities) was provided thoroughly, accurately documented and ensure treatment was provided when there were skin assessments forms completed but the assessment were inaccurate for one out of two sampled residents (Resident 1) 2. to provide showers regularly and as scheduled for one out of two sampled residents (Resident 1). These failures resulted in: A. inaccurate documentation of Resident 1's skin status, staff not identifying Resident 1 wound on top of his right shoulder, thereby no treatment was rendered on the wound on Resident 1's right shoulder, B. top of Resident 1's right shoulder developed a wound infection (invasion or growth of germs in the body) at the facility that was missed by the staff and, C. Resident 1's hospitalization on 8/6/24 with a diagnosis of sepsis (life threatening condition, a severe form of infection) secondary to cellulitis (bacterial infection of skin and tissue beneath your skin) and small abscess (a sign of infection, an enclosed collection of pus) of the right superior (towards the head end of the body) shoulder. Findings: A review of Resident 1's face sheet (demographics) indicated Resident 1 was admitted on [DATE] with a diagnoses of Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high) and Essential Hypertension (HTN, high blood pressure). Resident 1 had an additional diagnosis of Cellulitis (a deep bacterial infection of the skin) of upper limb when he came back from the hospital on 8/12/24. A review of Resident 1's Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 6/27/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13 out of 15 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1's MDS assessment indicated he was dependent on staff during dressing, toileting, bathing or showering and putting on or taking off footwear. A review of Resident 1's Clinical admission assessment (the process where nurses identify current and future care needs of the patient and identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient) conducted by the facility nurse dated 6/26/24 indicated Resident 1 had no wound on top of his right shoulder. A review of Resident 1's weekly skin checks completed by the nurses dated 6/26/24, 7/4/24,7/12/24, 7/19/24, 7/29/24, 8/5/24, and 8/12/24 did not indicate Resident 1 had a wound on his right shoulder. During a concurrent interview and weekly skin check record review on 8/15/24 at 12:00 p.m., the treatment nurse stated these weekly skin check documentations were inaccurate. A review of Resident 1's weekly skin checks completed by the nurses dated 7/19/24, 7/29/24, and 8/5/24, indicated Resident 1's skin was intact with no identified skin impairments. During a concurrent interview and weekly skin check dated 7/19/24, 7/29/24 and 8/5/24, record review on 8/15/24 at 12:00 p.m., the treatment nurse stated these weekly skin check documentations were incorrect. A review of Resident 1's electronic treatment administration record (ETAR, a report that serves as a legal record of the treatment administered to the residents) for 6/2024, 7/2024, 8/1/24 up to 8/6/24 indicated there was no treatment ordered and rendered for the wound on top of Resident 1's right shoulder. A review of Resident 1's electronic medication administration record (EMAR- electronic medical administration record) for 6/2024, 7/2024, 8/1/24 up to 8/6/24 there was no medication prescribed to indicate Resident 1 received any medication to treat the wound on top of his right shoulder . A review of Resident 1 hospital admission flow sheet wound note entry dated 8/7/24 indicated the wound on his right shoulder was present when Resident 1 was admitted at the hospital on 8/6/24. A review of Resident 1's hospital discharge note dated 8/12/24 indicated Resident 1 had a purulent (containing pus- a thick fluid containing dead tissue and bacteria, associated with infection) cellulitis with small superficial abscess of right superior shoulder and the sepsis was secondary to the cellulitis and small abscess of the right superior shoulder. A review of Skilled Nursing Facility Physician Transfer Orders dated 8/12/24 indicated Resident 1 had an order to treat Resident 1's right shoulder wound every Monday, Wednesday and Friday and an order for antibiotic (ABX, medicines that fight bacterial infections) for skin and soft tissue (refers to muscles, fats, or other supporting tissue of the body) infection. A review of the Clinical admission assessment conducted by the facility nurse dated 8/12/24 indicated Resident 1 had no abscess or wound on top of his right shoulder noted on Resident 1's admission skin sheet. A review of shower sheet for 7/2024 indicated Resident 1 should have received a total of 9 showers. Based on the documentation, Resident 1 only received 2 bed baths (washing someone in bed) out of 9 showers on these dates: 7/13/24 and 7/31/24. The shower sheet provided for 8/2024 indicated Resident 1 did not receive shower nor bed bath between 8/2/24 and 8/6/24. During an interview on 8/15/24 at 11:00 a.m., Resident 1 stated he had a wound on his shoulder for a while now and they were treating it now. Resident 1 stated no one looked at the wound on his shoulder before. During an interview on 8/15/24 at 11:00 a.m., Certified Nursing Assistant (CNA) A who was assigned to his care today, stated that as far as she knew, Resident 1 had no skin concern and had no wound on top of his right shoulder. During a concurrent observation in Resident 1's room and interview on 8/15/24 at 11:16 a.m., Licensed Nurse (LN) B stated Resident 1 had no wound on top of his right shoulder. CNA A and LN B appeared surprised to find Resident 1 had a dressing on top of his right shoulder. Visualization underneath the dressing on top of Resident 1's right shoulder indicated there was a circular wound with greenish thickened discharge. CNA A and LN B were surprised to learn Resident 1 had a wound on top of his right shoulder. When asked how come they did not know Resident 1 had abscess/ wound on top of his right shoulder, they did not respond. During an interview on 8/15/24 11:27 a.m., LN B, stated she was not aware of the abscess on Resident 1's right shoulder and did not know Resident 1 had abscess/ wound on top of his right shoulder until today. During a concurrent interview and record review of Resident 1's face sheet, discharge hospital note dated 8/12/24, weekly skin assessments on 8/15/24 at 12:00 p.m., the Treatment Nurse (TN C) verified Resident 1 was initially admitted on [DATE] and was readmitted on [DATE]. TN C stated initial skin assessment on 6/26/24 indicated Resident 1 had no wound noted on top of his right shoulder at that time. TN C stated the wound/abscess on top of Resident 1's right shoulder was acquired at the facility. When asked how Resident 1 might have acquired it, TN C did not respond. TN C stated Resident 1's hospital discharge note dated 8/12/24, indicated Resident 1 had a purulent (containing pus- a thick fluid containing dead tissue and bacteria, associated with infection) cellulitis with small superficial abscess of right superior shoulder and the sepsis was secondary to the cellulitis and small abscess of the right superior shoulder. TN C verified there was no abscess or wound on top of his right shoulder noted on Resident 1's facility admission skin sheet dated 8/12/24. TN C stated she only caught the abscess/wound on top of Resident 1's shoulder yesterday (8/14/24) and did not know it was there when he was readmitted to the facility on [DATE]. TN C stated she did not do a full skin assessment on Resident 1 when he returned from the hospital and did not read the hospital discharge note that was why she did not know about the abscess/wound on top of Resident 1's right shoulder. TN C verified the weekly skin checks by the nurses at the facility dated 6/26/24, 7/4/24,7/12/24, 7/19/24, 7/29/24, 8/5/24 and 8/12/24 were inaccurate and the weekly skin checks completed by the nurses dated 7/19/24, 7/29/24, 8/5/24 indicating Resident 1's skin was intact with no identified skin impairments were incorrect . TN C stated upon review of Resident 1 electronic medical record, she could not determine how and when this abscess/wound on Resident 1 right shoulder started at the facility. TN C stated that when Resident 1 was sent to the hospital, he already had an infected wound and was septic. TN C stated while Resident 1 was still at the facility, Resident 1 did not have a thorough and accurate skin assessments, so the nurses missed the wound on top of his right shoulder, the wound on top of his right shoulder got infected because no one was looking into it and there was no one cleaning and treating the wound at the top of Resident 1's right shoulder. TN C stated the nurses missed the wound infection, the infection worsened and Resident 1 probably already had sepsis before he was sent to the hospital. TN C stated Resident 1's sepsis resulted in hospitalization. TN C stated sepsis could be life threatening. TN C stated on Resident 1's initial admission on [DATE] up to when he was sent out to the hospital on 8/6/24, there was no mention of a wound on top of Resident 1's right shoulder on the skin assessments and no treatment rendered on the wound on top of his right shoulder and could be the reason why the wound got infected. When asked why Resident 1's wound on top of his right shoulder was missed, she stated Resident 1 was hard to assess and a lot of staff were scared of him. TN C stated accurate skin assessment were important to ensure residents were receiving the correct and appropriate treatment, to heal the wound, to prevent worsening of wound and to prevent infection. During an interview on 8/15/24 at 1:10 p.m., Licensed Nurse D stated if a resident was sent to the hospital and was diagnosed with sepsis at the hospital, it meant the resident already had an infection at the facility that was missed, not treated with ABX and had worsened. Licensed Nurse D stated untreated urinary tract infection (UTI, illness in any part of the urinary tract, the system of organs that makes urine) and infected wound could be a source for sepsis. LN D stated Resident 1 was scheduled to receive showers twice a week and more often as needed. LN D stated not providing regular showers to residents could result in skin impairment, development of wound, wound infection, missed skin impairment, low self-esteem, and bad odor. LN D stated accurate assessment and accurate documentation of skin impairments ensured quality care, decreased the risk of miscommunication and ensured residents received the right care to decrease risk of complication. During an interview on 8/15/24 at 1:13 p.m., CNA E stated sepsis could be a result of an infection that had worsen because it was missed and not treated. CNA E stated residents were scheduled to receive showers at the facility twice a week and more often as needed. CNA E stated it was important for residents well-being to receive showers as scheduled regularly. CNA E stated not providing showers to residents regularly as scheduled could lead to wound infection, skin impairment, development of wound or pressure ulcer (bed sores, injury to skin and underlying tissue resulting from prolonged pressure on the skin), worsening of wound or pressure ulcer or missed skin impairment. During an interview on 8/15/24 at 1:15 p.m., CNA F stated sepsis was a severe form of infection and it was an infection of the blood. CNA F stated it was a life-threatening condition. CNA F stated sepsis could be a result of UTI or an infected wound that was not treated. CNA F stated residents were scheduled to receive showers twice a week and more often as needed. CNA F stated part of giving bed bath/showers were looking at resident's skin and notifying the nurse of any wound or skin impairment. CNA F stated not providing showers regularly as scheduled could result in skin impairment, development of wound, wound to worsen, wound infection, sepsis, and missed skin impairment. During an interview on 8/15/24 at 1:21 p.m., LN B stated residents were scheduled to receive showers twice a week and more often as needed. LN B stated not receiving showers regularly and as scheduled could lead to wound infection, missed skin impairment, development or worsening of wound or pressure ulcer. LN B stated residents would also have low self-esteem or they might feel uncomfortable. LN B stated if a resident was sent to the hospital and the diagnosis was sepsis, it meant resident already had an infection at the facility that was missed and was not treated with ABX. LN B stated sepsis was life threating and source could be from untreated UTI or infected wound. During an interview on 8/15/24 at 1:25 p.m., when asked how come the staff did not know Resident 1 had a wound on top of his right shoulder before until today, the Assistant Director of Nursing (ADON) was silent. The ADON stated if a resident was sent to the hospital and the diagnosis was sepsis, it meant the infection started at the facility, was not treated, and had worsened. The ADON stated sepsis could be a result of untreated, infected wound or UTI. The ADON stated sepsis could result in hospitalization and death. During an interview on 8/15/24 at 1:35 p.m., LN G stated residents were scheduled to receive showers twice a week or more often as needed. LN G stated not providing showers or bed bath to residents regularly placed them at risk for skin impairments, for staff to miss residents skin impairments, wound to become infected, development of sores or worsening of sores. LN G stated if a resident was sent to the hospital and the diagnosis was sepsis, it meant resident already had an infection at the facility that was missed and not treated. LN G stated sepsis could be a result of untreated UTI or wound infection. During a concurrent interview and shower sheet record review on 8/15/24 at 1:50 p.m., the ADON stated residents were scheduled to receive showers twice a week and more often as needed. The ADON stated residents should receive at least 8 to 9 showers in a month. The ADON verified Resident 1 was scheduled to receive showers on Mondays and Thursdays. The ADON verified the shower sheet for 7/2024 indicated Resident 1 should have received a total of 9 showers, but only received 2 bed baths out of 9 showers on these dates 7/13/24 and 7/30/24. The ADON verified that from 8/2/24 up to 8/6/24, Resident 1 did not receive any showers or bed bath at all. The ADON verified the shower documentation indicated Resident 1 was not receiving shower/bed bath regularly. The ADON stated CNAs providing showers or bed baths were supposed to document skin impairments and report to nurses their findings. The ADON stated not providing showers regularly and not assessing resident's skin thoroughly was a contributing factor on why Resident 1's wound on top of his right shoulder was missed and why the wound on top of his right shoulder became infected. The ADON verified there was no treatment initiated for Resident 1's wound on top of his right shoulder until he was back from the hospital on 8/12/24. A review of the facility 's policy and procedure (P&P) titled Skin and Wound Management, revised 1/1/12, the P&P indicated the staff will take appropriate measure to prevent and reduce the likelihood that residents will develop pressure ulcer and or other skin conditions .CNAs will complete body checks on residents shower days and report unusual findings. A review of the facility 's policy and procedure (P&P) titled Showering and Bathing revised 1/1/2012, the P&P indicated observing the skin is performed during bathing. A review of the The Cleveland Clinic publication on skin care on 4/27/2020 indicated . we come in contact with thousands of allergens every day. Showering rinses off those allergens, as well as bacteria and viruses. A review of Healthline published skin care dated 1/29/2019 indicated .Poor hygiene or infrequent showers can cause a buildup of dead skin cells, dirt, and sweat on your skin. Showering too little can also trigger an imbalance of good and bad bacteria on your skin and too much bad bacteria on your skin also puts you at risk for skin infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who was at high risk for falls and had a history of falls, was provided supervision by direct care staff, and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. Facility policies (Titled, Resident Safety, Fall Management Program, and Comprehensive Person-Centered Care Planning) on safety and management of falls were not followed. As a result, Resident 1 suffered a fall that resulted in a 15 cm (Centimeter) laceration (deep cut) to the scalp, which required him to be transferred to a General Acute Care Hospital (GACH) emergency department (ED) to receive 14 staples to repair the laceration. Findings: During a review of Resident 1's admission RECORD, dated 3/28/23, the record indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Alzheimer's Disease (A brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and Complete Traumatic Amputation (The loss of a body part that occurs as the result of an accident or injury) at Knee Level of the Right and Left Lower Legs. Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 1/21/23 indicated his BIMS (Brief Interview of Mental Status-A cognition [ the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 4, which indicated his cognition was severely impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Record review of Resident 1's MDS also indicated he required extensive assistance of one person for bed mobility and toilet use, and limited assistance of one person for transfers. During an interview with the Director of Nursing (DON) on 3/29/23 at 8:55 a.m., she stated Resident 1 would not use the call light to request assistance, could get hurt with self-transfers, and his judgment was poor. She also stated he forgot to lock the brakes of his wheelchair. During a concurrent interview and observation on 3/29/23 at 9:09 a.m., in the conference room of the facility, a laceration the size of a tennis ball was observed on Resident 1's scalp. The entire area was black in color and appeared to be covered with dried blood. 14 staples were observed on the laceration. When asked if it was painful, he stated that if touched, it did hurt pretty bad. During an interview with Licensed Staff A, on 3/29/23 at 10:03 a.m., she stated Resident 1 was confused and had impaired judgment due to dementia (Memory loss). She sated she checked on him routinely every two hours, but there was no specific time requirement to check on him, and no log to document visual checks. During an interview with Unlicensed Staff B on 3/29/23 at 10:08 p.m., she stated she had known Resident 1 for about 11 years. Unlicensed Staff B corroborated Licensed Staff A's story, stating on some days Resident 1 was very confused, and he would not use the call light to request assistance. Unlicensed Staff B stated she checked on Resident 1 every hour, but there was no log to document visual checks. During a review of Resident 1's Fall Risk Evaluation, dated 6/20/22, the evaluation indicated he was at risk for falls. During a review of an e-mail sent by the Director of Nursing (DON) on 5/12/23 at 3:44 p.m., the e-mail indicated the DON was unable to find a care plan for prevention of falls for Resident 1. Resident 1 had been determined to be at risk for falls on the Fall Risk Evaluation dated 6/20/22. First Fall: Record review of an IDT (Interdisciplinary Team- Team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Note dated 8/18/22 at 9:38 a.m., indicated, resident [Resident 1] had actual unwitnessed fall 8/17 [8/17/22] with minor injury r/t [Related to] poor short-term memory/recall; transferred to [GACH] ED for eval [Evaluation] and tx [Treatment], cleared, returned to facility approx. [Approximately] 2000 [8:00 p.m]. Record review of a care plan for falls initiated on 8/17/22 after the fall, indicated, Continue interventions on the at-risk plan [Difference between the at-risk plan and regular care plan unkown, but no care plans for fall prevention were found prior to 8/17/22, as indicated by an e-mail sent by the DON on 5/12/23 at 3:44 p.m.] .Provide activities that promote exercise and strength building where possible. There were no other interventions in the plan of care to prevent falls, as other interventions were aimed at providing post-fall care to Resident 1 such as monitoring for bruises and notifying the doctor for any changes in level of consciousness. Record review of a facility document titled, Fall Risk Evaluation, dated 9/01/22 at 2:33 a.m., completed two weeks after Resident 1's fall at the facility, which occurred on 8/17/22, indicated he was at risk for falls. Record review of an e-mail sent by the DON on 5/18/23 at 12:33 a.m., the DON indicated, The risk assessment should be updated post fall as soon as possible. During a review of an e-mail sent by the DON on 5/12/23 at 3:44 p.m., the e-mail indicated the DON was unable to find a neurological checks (A series of tests to determine whether the nervous system is impaired) performed at different time intervals after the fall, which was a requirement for unwitnessed falls in the facility policy titled, Fall Management Program, last revised in March 13, 2021. The e-mail from the DON indicated, A paper neurocheck (A nursing assessment documented in paper to check for injury to the brain or spine after a fall) is not located. It appears that the resident was cleared at the Emergency Department and neuro checks did not resume upon return. Record review of an e-mail sent by the Surveyor to the DON on 5/10/23 at 11:54 a.m., the DON was asked what type of supervision was provided to Resident 1 after the fall on 8/17/22. The DON responded through an e-mail sent on 5/12/23 at 3:44 p.m., that indicated, The attached Nurse's notes describe the assigned visual supervision post fall. The nursing notes the DON attached (Nursing notes from 8/21/22 to 3/12/23) did not indicate Resident 1 was getting visual checks or seen more than once per shift; for example, one of the notes documented on 8/20/22 at 3:34 p.m., indicated, Resident is alert and oriented. Was well cared for, ate his meal. Due medications were administered as prescribed with good effect. Second Fall: Record review of an incident report dated 10/06/22 at 7:06 p.m. indicated, Resident [Resident 1] found sitting in wheelchair, with an abrasion on his forehead, stating he'd fallen from his chair. Resident stated he was attempting to transfer from his bed to his wheelchair, and his stump got caught on the lever under the bed, and he fell, sliding over and hitting his head on the bedside table. Record review of a Fall Risk Evaluation dated 10/06/22 at 10:06 p.m. indicated Resident 1 was at low risk for falls, although he had just fallen earlier that evening. One of the questions in this evaluation was left unanswered, possibly giving it an incorrect score. This was confirmed by the DON, through an e-mail sent on 5/12/23 at 3:44 p.m., in which she indicated, The fall risk dated 10/6/22 is not accurate. During a review of an e-mail sent by the Director of Nursing (DON) on 5/12/23 at 3:44 p.m., the e-mail indicated the DON was unable to find an updated or revised care plan for prevention of falls, created after the fall on 10/06/22. Record review of a facility document titled, Neurological Flow Sheet, initiated on 10/06/22 at 5:45 p.m., indicated to perform neurological checks every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 1 hour for 4 hours, followed by every 4 hours for 72 hours. This document indicated neurological checks were scheduled to be performed at 8:30 p.m., 9:30 p.m., 10:30 p.m. and 11:30 p.m. on 10/06/22, but instead, the neurological checks were performed at 8:30 p.m., 9:30 p.m., 10:30 p.m., on 10/06/22, and at 2:30 a.m. on 10/07/22. For a time lapse of 4 hours from 10:30 p.m. on 10/06/22 to 2:30 a.m. on 10/07/22, there was no data showing Resident 1 received the scheduled neurological checks, although he had an unwitnessed fall, where he hit his head. Third Fall: Record review of an IDT note dated 11/08/22 at 9:51 a.m., indicated, [Resident 1] had an unwitnessed, non-injury fall 11/8 [11/08/22] @ [At] approx. 0115 [1:15 a.m.] r/t dementia, poor safety awareness, recall. He was self transferring after using the bathroom and slipped out of w/c [Wheelchair] because w/c brake was not engaged. Record review of a Fall Risk Evaluation dated 11/08/22 at 3:05 a.m., did not indicate he was at risk for falls since he received a score of 9, due to inaccurate data entry. The second question in this evaluation asked how many falls this resident had in the last three months. The question was answered as, 1-2 falls in past 3 months, when, in reality, Resident 1 had three falls since 8/17/22, according to documentation provided by the facility (Fall on 8/17/22, fall on 10/06/22 & fall on 11/08/22). Record review of a facility document titled, Neurological Flow Sheet, initiated on 11/08/22 at 1:00 a.m., indicated to perform neurological checks every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 1 hour for 4 hours, followed by every 4 hours for 72 hours. This document indicated neurological checks were scheduled to be performed at 11:00 p.m. on 11/10/22 and at 2:00 a.m. on 11/11/22 but these neurological checks were incomplete, missing essential information including level of consciousness, hand grasps, and pupil reactions (Pupillary dilation [Increase in diameter] and pupillary constriction [Decrease in diameter] in response to light or absence of light). During a review of an e-mail sent by the Director of Nursing (DON) on 5/12/23 at 3:44 p.m., the e-mail indicated the DON was unable to find an updated or revised care plan for prevention of falls, created after the fall on 11/08/22. Fourth Fall: Record review of a facility incident report dated 11/20/22 at 2:30 p.m., indicated, At approx. 1530 [3:30 p.m.] Side 1 assigned charge nurse and another resident heard a loud noise. Upon reaching residents [Resident 1's] room, he was found lying on the floor by his TV stand flat on his back. Resident's forehead was bleeding and (Sic) a small abrasion (Wound to the top layers of the skin) on L [Left] Hand. Charge nurse observed blood on TV stand and floor. Residents motorized w/c was by his feet and his headphones were by his head. He started to lean forward and grab his headphones and fell out of the chair or the chair moved, [Resident 1] was unsure. Resident advised to lay still, not moving neck until EMS [Emergency Medical Services] arrived .bleeding from mouth noted that resident had bitten his tongue. EMS arrived approx. 1540 [3:40 p.m.] .Resident transported to [GACH] ED for eval and tx [Evaluation and treatment]. Record review of a Fall Risk Evaluation dated 11/20/22 at 5:30 p.m., indicated Resident 1 was at risk for falls. Record review of the care plan for falls dated 11/20/23 indicated the plan was revised to prevent further falls, but the care plan did not mention anything related to supervision of Resident 1, or increased safety monitoring to prevent reoccurrence of the fall. The revisons to the care plan included, Anticipate [Resident 1's] needs and meet his needs as requested .Ensure call light is within reach .[Resident 1] needs a safe environment with even floors free from spills and/or clutter. Record review of an e-mail sent by the DON on 5/18/23 at 12:33 p.m., indicated no neurological checks were found for this fall, although the fall was unwitnessed, and Resident 1's forehead was observed bleeding, which indicated he may have hit his head, per the facility incident report dated 11/20/22 at 2:30 p.m. Fifth Fall: Record review of a facility incident report dated 3/09/23 at 3:15 p.m., indicated, Resident [Resident 1] slid out of w/c participating in activities playing kick ball witnessed by activities coordinator. Not wearing seat belt in W/C .refuses. Record review of a Fall Risk Evaluation dated 3/14/23 at 1:59 p.m., indicated Resident 1 was at risk for falls. Record review of a plan of care for falls initiated on 3/10/23 indicated appropriate interventions were implemented to prevent further falls for Resident 1 but did not mention anything in regard to supervision of the resident. Sixth Fall: Record review of an IDT Progress Note dated 3/20/23 at 5:02 p.m., indicated, Resident had a fall next to his bed 3/19/23 around 3am .During this event, wheelchair was tipped over and it is unclear exactly what resident was doing. It appeared to the nurse he was self-transferring, but his (Sic) Alzheimer's dementia he does not recall .He sustained a laceration to his left posterior scalp. First aid and stabilization provided and 911 called. Resident returned from ED with the laceration stapled and report of no other injury. Record review of a document titled, ED Prov [Provider] Note, dated 3/20/23 at 12:02 a.m., from the GACH where Resident 1 was transferred on 3/19/23 after the fall, indicated, This is a [AGE] year old male who was sent in from the nursing home for mechanical fall .Patient suffered a large laceration to the top of his scalp .Laceration details: Location: Scalp .Scalp location: Crown Length (cm): 15 Depth (mm): 10 .Repair method: Staples Number of staples: 14. Record review of a Fall Risk Evaluation dated 3/19/23 at 4:22 p.m. indicated Resident 1 was at risk for falls. Record review of the care plan for prevention of falls initiated on 3/19/23 listed interventions to prevent further falls but did not indicate the need for increased supervision of Resident 1, or anything regarding increased safety monitoring for prevention of further falls. Record review of a facility document titled, Neurological Flow Sheet, initiated on 3/19/23 at 3:30 a.m., indicated to perform neurological checks every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 1 hour for 4 hours, followed by every 4 hours for 72 hours. This document indicated neurological checks were scheduled to be performed at 9:00 a.m., 1:00 p.m. and 5:00 p.m. on 3/20/23, but these neurological checks were either undocumented or incomplete (Example: No documentation of hand grasps or pupil reactions on 3/20/23 at 9:00 a.m., 1:00 p.m., and 5:00 p.m., and no documentation in general of neurological checks on 3/20/23 at 1:00 p.m.), although Resident 1 had just suffered a fall on 3/19/23 that resulted in a 15 cm laceration to the scalp area during an unwitnessed fall. During a phone interview with Unlicensed Staff C on 5/22/23 at 1:09 p.m., he stated the night of the fall on 3/19/23, he was assigned to Resident 1. Unlicensed Staff C stated he was also assigned to two other residents at risk for falls that required very close supervision, whose rooms where in another hallway of the facility. Unlicensed Staff C stated he could not clearly remember if they were having a staffing shortage that night, but knew the facility needed more certified nursing assistants given the number of residents that were at risk for falls, including Resident 1. Unlicensed Staff C stated he had at least 10 residents assigned to his care that night, so he did the best he could. During a phone interview with Licensed Staff D on 5/22/23 at 1:25 p.m., she stated she was the assigned nurse for Resident 1 the night of the fall on 3/19/23. Licensed Staff D stated Resident 1 was using his electric wheelchair that night, driving up and down the hallways of the facility. Licensed Staff D stated she last rounded on him sometime between 1:30 a.m. to 2:00 a.m. (The fall happened at approximately 3:00 a.m. according to the IDT Progress Note dated 3/20/23 at 5:02 p.m.). Licensed Staff D stated she hear a loud thump and found him on the floor in his room in-between his wheelchair and the bed, alert but confused as to what was going on. Licensed Staff D stated that since this fall, Resident 1 had been experiencing a steady decline. Record review of a posting dated 3/20/23, attached to Resident 1's door, indicated, CARE ALERT .RESIDENT MAY NEVER SELF TRANSFER HE REQUIRES SUPERVISION .RESIDENT MAY NOT BE IN W/C IN ROOM. Record review of an e-mail sent by the DON on 5/18/23 at 12:33 a.m., the DON responded to a question by the Surveyor on how she ensured the instructions in the posting attached to Resident 1's door was being followed. The DON indicated, The Care Alert is posted in the resident's room and on his door. A clipboard in-service was done 5/15/23 to make sure care staff have read the Care Alert, proof attached. Verbal training has been done on this Care Alert since the fall, however I cannot provide proof of verbal training done by myself and the MDS nurse. There is no log or sign in/sign out. Record review of the facility policy titled, Resident Safety, last revised on April 15, 2021, indicated, During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident's safety risk (e.g., fall) .After a risk evaluation is completed, a Resident-centered care plan will be developed to mitigate safety risk factors .The IDT will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors. Record review of the facility policy titled, Fall Management Program, last revised on March 13, 2021, indicated, A licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of a significant change of condition, post fall and as needed .The IDT will initiate, review and update the Resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change in condition, post fall and as needed .Perform neurological checks at the ordered frequency or as the listed below equaling 72 hours a. Every 15 minutes x 1 hour, then b. Every 30 minutes x 1 hour, then c. Every hour x 4 hours, then d. Every 4 hours x 66 hours OR until the physician states it is no longer necessary OR after 72 hours if the Resident's condition is stable .A Resident who endures more than one fall in a day, week or month, will be considered at high risk for falls B. Monthly, for those identified as high risk for falls, the IDT will meet to review the fall risk interventions for appropriateness and effectiveness until the frequency of their falls diminishes C. The Residents' care plans will be updated with the IDT's recommendations. Record review of the facility policy titled, Comprehensive Person-Centered Care Planning, last revised in November of 2018, indicated, Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed .The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment .the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition .v. Other times as appropriate or necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records review, the facility failed to provide required physical assistance to transfer one of two sampled residents (Resident 1) when Resident 1's Minimum Data Set (MDS -health status screening and assessment tool used for all residents) indicated Resident 1 required two or more person physical assistance with transfer. This failure resulted to Resident 1 falling on her right foot sustaining a right fibula fracture (a break to the fibula (A lower-leg bone that extends from the knee to the outside of the ankle parallel to the tibia [shinbone]) caused by a forceful impact that results in injury) which caused Resident 1 to experience constant pain and not being able to bear weight to her right foot when standing. Findings: During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with a diagnoses including but not limited to Muscle Weakness; Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems); and Rheumatoid Arthritis (a chronic (long-lasting) autoimmune disease [condition in which the body's immune system mistakes its own healthy tissues as foreign and attacks them] that mostly affects joints). During a record review for Resident 1, the MDS dated [DATE] indicated Resident 1 had a BIMS score of 14 out of 15. (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 1 had a body weight of 211 lbs. (pounds - a unit for measuring weight) requiring extensive (resident involved in activity; staff provide weightbearing support) two or more person physical assistance with transfer. During a record review for Resident 1, the document titled, Fall Risk Evaluation dated 5/30/23 indicated Resident 1 had a balance problem while standing. During a record review for Resident 1, the Progress Note titled, Alert Note dated 6/29/23 at 7:00 a.m. indicated, a CNA reported to Licensed Staff A that CNA tried to transfer Resident 1 to her wheelchair; however, the CNA could not make a successful transfer and lowered Resident 1 to the floor. During a record review for Resident 1, the Progress Note titled, IDT (Interdisciplinary Team - group of health care professionals who work together toward the goals of the resident) Progress Notes - Fall dated 7/03/23 at 2:28 p.m. indicated, Fall 6/29/23 early morning as CNA attempted to assist resident to transfer bed to wheelchair. During transfer resident was wearing grip socks (footwear designed to provide extra traction on slippery surfaces), [Resident 1] suddenly lost ability to stand and was lowered to ground gently by the CNA. Resident denied pain and was able to continue the day with therapy. Later however her right ankle was turning purple, and [Resident 1] sent to ED (Emergency Department). Returned with finding right fibular fracture. During a record review for Resident 1, the Progress Note titled, Post Fall Evaluation dated 07/10/2023 at 5:17 p.m. indicated Resident 1 had bruising to her right shin and ankle. The document indicated Resident 1 was in constant pain. During a record review for Resident 1, the Progress Note titled, Health Status Note dated 7/11/23 at 4:46 a.m. indicated Resident 1 returned from Orthopedic (is a specialized medical field with a primary focus on the musculoskeletal system) with her right ankle casted (orthopedic device used to protect and support broken or injured bones and joints). The document indicated, NWB (Non Weight [NAME] means that you can't put any weight on your injured lower leg for a period of time, which can be anything from weeks to months) to RLE (Right Lower extremity - hips, legs, ankles, and feet are all considered lower extremities) and no ankle ROM (Range of Motion - the extent or limit to which a part of the body can be moved around a joint or a fixed point). During a record review for Resident 1, the Medication Administration Record (MAR) had an entry order to assess for pain every shift. The MAR from 7/01/23 to 7/12/23 indicate Resident 1 experienced moderate pain on 7/2/23, 7/04/23, 7/05/23, 7/07/23, 7/08/23, 7/10/23, 7/11/23 and 7/12/23. During an interview with Unlicensed Staff B on 7/13/23 at 12:26 p.m., Unlicensed Staff B stated Resident 1 required two-person assist with transfer before she fractured her foot. During an interview with the Physical Therapy Assistant (PTA - work under the direction and supervision of Physical Therapists [a healthcare provider who helps you improve how your body performs physical movements]) on 7/12/23 at 12:36 p.m. The PTA stated Resident 1 required maximum assist of two-person with transfer prior to the 6/29/23 fall. The PTA stated CNAs were aware that Resident 1 required two-person assist with transfer since her initial admission to the facility. During an observation and concurrent interview with Resident 1 in her room on 7/13/23 at 12:38 p.m., Resident 1 was observed with a leg cast to her right foot. Resident 1 stated a female CNA was transferring her in the morning of 6/29/23 to a rolling chair (wheeled chair) when her left foot lost balance, fell down and landed on her right foot. Resident 1 stated she broke one of her bones on her right foot and had been hurting pretty bad. Resident 1 stated she would ask for pain medication at least three times a day to relieve the pain. Resident 1 also stated, it is more difficult to stand now with just one foot. During an interview with Unlicensed Staff C on 7/13/23 at 12:44 p.m., Unlicensed Staff C stated Resident 1 always required two-person assist even prior to her breaking her foot. When asked about the risk for Resident 1 if she was transferred with one person, Unlicensed Staff C stated Resident 1 could fall which could result to an injury. Review of the Facility policy and procedure titled, Transfer of Residents, revised on 4/27/23 indicated, Residents will be lifted or transferred according to the assessment and needs of residents and To provide the form of transfer best suited to the residents' needs and to maintain resident/staff safety during the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five residents sampled for falls review (Resident 4) received care and services to prevent falls in accordance with Resident 4's fall risk factors and professional standards of practice. For Resident 4, who had a documented history of falls, poor gait, poor balance, and muscle weakness: (1) The facility failed to perform a fall risk evaluation after Resident 4 fell on 5/20/22 while Resident 4 was attending physical therapy, and after a nursing assessment on 5/22/22 indicated Resident 4 had poor balance and unsteady gate; (2) The facility failed to accurately evaluate Resident 4's risk for falls when a nursing assessment dated [DATE] indicated Resident 4 had no previous falls, when Resident 4 had fallen two days earlier on 5/20/22; (3) The facility failed to review, update, and develop a fall prevention care plan after Resident 4 fell on 5/20/22, leaving in place an outdated fall care plan dated 12/31/21; (4) The facility failed to accurately document Resident 4's falls when a nursing note dated 6/5/22, at 2:46 a.m., indicated Resident 4 had a fall on 6/5/22, at 3:30 a.m., and the Director of Nursing was notified of the fall on 6/5/22 at 2:58 a.m; (5) The facility failed to review, update, and develop a fall prevention after Resident 4 fell again on 6/5/22, relying on an Occupational Therapy care plan created on 6/16/22 to address Resident 4's muscle weakness; (6) The facility failed to timely and accurately evaluate Resident 4's risk for falls when a fall risk assessment for the 6/5/22 fall was completed on 6/20/22, 15 days after the fall, and the fall risk assessment indicated Resident 4 had no gait and or balance problems and no decreased muscular coordination; (7) The facility further failed to accurately evaluate Resident 4's risk for falls when Resident 4's MDS ASSESSMENTS (a standardized, federally mandated clinical assessment tool that drives the creation of care plans and interventions for residents), dated 3/25/22 and 6/24/22, did not indicate Resident 4 had falls at the facility since admission; (8) The facility failed to implement fall prevention interventions for Resident 4 to address her fall risk factors of poor balance, poor gait, and muscle weakness after Resident 4's second fall on 6/5/22, and (9) The facility failed to ensure Resident 4 was properly supervised and assisted during transfers and ambulation in her room on 7/15/22 when a Physical Therapy Student (PTS) assigned to escort Resident 4 to the gym did not assist, supervise, and apply a gait belt to Resident 4 during her transfer and ambulation from her bed to the hallway, which resulted in Resident 4 falling to the floor, breaking her leg and experiencing severe pain; this failure was compounded by the fact that Resident 4 had previously sustained another fall with injury, also while ambulating and in the care of physical therapy staff, two months earlier, on 5/20/22, which should have alerted the PTS of the need for increased supervision and assistance for Resident 4 during physical therapy. These failures resulted in Resident 4 sustaining two falls at the facility, on 6/5/22 and on 7/15/22, with the last fall resulting in Resident 4 breaking her left leg and experiencing sustained severe pain for up to seven days after the fall. Findings: A review of Resident 4's FACESHEET indicated she was admitted on [DATE] with diagnoses including diabetes mellitus, hypertension, memory deficit following cerebrovascular disease and chronic pain. A review of Resident 4's PROGRESS NOTES indicated physician note dated 12/23/21, at 12:58 p.m., titled SNF VISIT NOTE, indicating Resident 4 had sustained a fall, as follows: Called by RN [Registered Nurse] due to fall and pain and [Resident] was reaching and fell onto her right wrist and right shoulder. A review of Resident 4's care plans (documents instructing staff on how care for residents) indicated one nursing care plan related to falls, dated 12/23/21, titled The resident has had an actual fall . poor balance . The care plan listed the following interventions: determine and address causative factors, monitor for pain, bruises and change in mental status, and physical therapy consult. A review of Resident 4's FALL RISK EVALUATION dated 12/29/21, at 2:37 p.m., performed after Resident 4's fall on 12/23/22, indicated Resident 4 was not at a high risk for falls and had normal gait and balance. A review of Resident 4's MDS ASSESSMENT (a standardized, federally mandated clinical assessment tool that drives the creation of care plans and interventions for residents), dated 3/25/22, indicated Resident 4 needed the supervision and assistance of one person to transfer out of bed and for ambulation and locomotion. The MDS section titled FALL HISTORY had no falls documented for Resident 4. A review of Resident 4's FALL RISK EVALUATION dated 4/5/22, at 2:37 p.m., indicated Resident 4 was not at a high risk for falls and had normal gait and balance. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 5/20/22, at 7:37 p.m., titled ALERT NOTE, indicating Resident 4 had a fall that day while under the care of physical therapy staff. The note indicated Resident 4 fell outside on the sidewalk into the grass. The note further indicated Resident 4 suffered an abrasion on the left upper forehead, complained of headache, left knee pain, and bilateral wrist pain. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 5/22/22, at 2:53 a.m., titled WEEKLY EVALUATION, indicating the following: gait is unsteady, balance is poor, and range of motion impairment (how far you can move or stretch a part of your body) on both legs. The note indicated Resident 4 had no falls since previous WEEKLY EVALUATION. A review of Resident 4' PROGRESS NOTES indicated nursing note dated 6/5/22, at 2:46 a.m., titled POST FALL EVALUATION, indicating Resident 4 had a fall in her room on 6/5/22, at 3:30 a.m., while ambulating from the toilet to the bed in her room. The note indicated: Resident states she was coming out of the restroom and was weak and fell. The note indicated the fall was unwitnessed. The note further indicated: Reason for the fall was evident: .weakness. The note further indicated the fall resulted in hip injury/discomfort and required Emergency Room/Hospitalization. The note indicated Resident 4 had a history of falls. The note concluded Resident [4] was weak and unable to make it back to bed after coming out of restroom. A review of Resident 4's PROGRESS NOTES indicated physician note dated 6/9/22, but signed on 6/10/22, at 8:48 a.m., written by Resident 4's physician, titled FU [Follow Up] COVID and Fall, indicating: FU Fall . [Resident 4] is tearful and worried about her weakness . Has been feeling more weaker and with balance difficulty . A review of Resident 4's CARE PLANS indicated care plan created by the Occupational Therapist (OT) dated 6/16/22, titled, The resident has a decreased ability to perform self-care related to decreased ROM [range of motion], impaired activity tolerance, weakness . and contained the following interventions: Activities of Daily Living retraining, discharge planning, establish functional maintenance plan, OT treatment as indicated, pain modalities as needed, resident/family/caregiver education, and upper extremity therapeutic exercises . A review of Resident 4's FALL RISK EVALUATION, dated 6/20/22, at 1:44 p.m., indicated Resident 4 was at a HIGH RISK for falls. The evaluation, however, indicated Resident 4 had no balance problems standing or walking, had no decreased muscular coordination, had no change in gait when walking through doorways, and did not require the use of assistive devices (cane, walker, etc.) A review of Resident 4's MDS assessment dated [DATE] but completed on 6/11/22, indicated Resident 4 required STAFF SUPERVISION during transfers and locomotion and used a walker (a mobility device). The MDS section titled FALL HISTORY was blank, with no falls documented for Resident 4 in the past 6 months. Review of the Journal of the American Medical Association, Prevention of Falls in Older Adults, [NAME] 2018, a specialized literature, indicated that a recent history of falls is the single best predictor of future falls. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/15/22, at 9:32 a.m., titled POST FALL EVALUATION, indicating Resident 4 had a fall in her room on 7/15/22 at 9:32 a.m. while ambulating with physical therapy. The note indicated the fall was witnessed. The note further indicated the fall resulted in a fracture of her left fibula (calf bone), pain and the hospitalization of the resident. The note further indicated Was a safety evaluation completed/documented prior to the fall: No and Safety teaching documented before the fall: No. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/15/22, at 11:54 p.m., titled SYSTEM NOTE, indicating: Resident was sent to [Hospital] for X-rays of Left Foot and ankle . [Hospital] called the facility approximately at 4:30 p.m. to report Resident was found to have a left Fibula fx [fracture] and she would be returning with a walking boot, a walker, and a prescription for pain medications. Resident returned to the facility at 1740 hours [5:40 p.m.] A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/16/22, at 4:04 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 9 [on a scale of 0-10, with 0 being no pain, and 10 the worst pain]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/16/22, at 9:59 p.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 9 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/17/22, at 4:41 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 9 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/17/22, at 6:55 p.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 8 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/18/22, at 11:30 a.m., titled IDT NOTE, indicating Resident had assisted fall w/injury 7/15: was in room, walked to doorway to meet with therapy and stated that she became light-headed and felt legs weak and would not support her, was supported/guided to floor by therapy. C/o [complains of] LLE [lower left extremity] pain; transferred to [Hospital] ED for eval and tx [treatment]; confirmed fibula fragility fracture . A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/19/22, at 00:49 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 7 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/20/22, at 2:37 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 8 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/21/22, at 6:08 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 7 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/22/22, at 9:48 p.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 9 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated nursing note dated 7/24/22, at 4:17 a.m., titled ADMINISTRATION NOTE, indicating Resident 4's pain on her left leg was 7 [on a scale of 0-10]. A review of Resident 4's PROGRESS NOTES indicated physician note dated 7/25/22, at 6:22 p.m., written by Resident 4's physician, titled PHONE NOTE, indicating Received a call from [DON] [Resident 4] is in a lot of pain. During an interview on 7/25/22, at 2:05 p.m., the DON stated Resident 4 fell on 7/15/22, at 9:30 a.m., and broke her left fibula (the calf bone) because of the fall. The DON described the incident as follows: in the morning of 7/15/22 Resident 4 was in her room waiting for physical therapy; a Physical Therapy Student (PTS) went to Resident 4's room and stood at the doorway; the PTS called Resident 4 and waited for her at the doorway; Resident 4 got out of bed and started walking towards the doorway, unassisted and unsupervised by staff, and without a gait bell (belt used by a caregiver on a patient with mobility issues to assist with transfers); when Resident 4 reached the door her legs gave way and she fell to the floor; the PTS assisted Resident 4 to the ground. During the same interview on 7/25/22, at 2:05 p.m., the DON reviewed Resident 4's clinical record. The DON stated Resident 4 had a history of falls, muscle weakness, unsteady gait, and poor balance. The DON stated for a resident with these risk factors appropriate fall interventions included increased staff supervision, frequent checks, and educating the resident to use the call light and requesting staff assistance prior to getting up and ambulating. The DON was asked if these interventions were part of Resident 4's care plans and were implemented. The DON reviewed Resident 4's clinical record and confirmed there were only two fall care plans created for Resident 4, the first created on 12/23/21 by nursing staff, and the other on 6/16/22 by the Occupational Therapist. The DON confirmed none of the care plans contained the fall prevention interventions of increased staff supervision, frequent checks, and educating the resident to use the call light and request staff assistance prior to getting up and ambulating. The DON confirmed the only three fall prevention evaluations completed for Resident 4, on 12/29/21, 4/5/21 and 6/20/21. During an observation on 7/26/22, 9:30 a.m., Resident 4 was lying in bed. During a concurrent interview, Resident 4 was alert and oriented, and described the 7/15/22 fall as follows: she was in bed waiting for physical therapy; the PTS came to her room but did not come in, she stood outside the doorway; physical therapy staff did not enter resident rooms because they did not want to go through the trouble of applying gowns, gloves, mask and faceshield (required of staff when entering resident rooms in the facility); from the door, the PTS indicated it was time for physical therapy; there was no staff in the room to help her get out of bed; she got out of bed and started walking unassisted towards the PTS who was waiting at the door; she had no gait belt; when she reached the doorway she felt weakness in her legs, lost her balance, and fell to the floor; the PTS did not assist her to do the floor; Resident 4 tried to grab the door frame for support but to no avail; after the fall she felt severe pain on her left leg, 12 on a 0-10 scale. During an observation on 7/26/22, at 9:55 a.m., the Physical Therapy Assistant (PTA) was outside Resident 21's room, standing in the doorway. During a concurrent interview, the PTA stated she was waiting for Resident 21 to come out to take him to physical therapy. While PTA was waiting outside resident's room, Resident 21 transferred himself unassisted to a wheelchair and was pushing himself towards the door. During an interview on 7/26/22, 10:08 a.m., the Occupational Therapist (OT) stated he was treating Resident 4 and was familiar with her health conditions and physical limitations. The OT stated he started treating Resident 4 on 6/16/22, after her 6/5/22 fall, to improve her range of motion. The OT stated Resident 4 always complained of weakness. The OT stated Resident 4 needed a gait belt (a speciazlied belt placed by a caregiver around a person with mobility issues during transfers to prevent and mitigate falls) during transfers and close staff supervision when ambulating because of her muscle weakness and poor strength. A review of facility policy and procedure titled FALL MANAGEMENT PROGRAM, dated 3/13/21, indicated: As part of the admission Assessment, the licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on the Resident's care plan. Document interventions for every Resident regardless of fall risk evaluation score. A licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of significant change in condition, post fall and as needed. The Interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the identified risk factors and root causes . The IDT will initiate, review and update the Resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall and as needed. The licensed nurse will evaluate the Resident's response to the interventions on the Weekly Summary and update the Resident's care plan as necessary. Following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the Resident's care plan as necessary. The IDT will review the circumstances surrounding the fall then summarize their conclusions on an IDT note. In an effort to prevent more falls, the IDT will review and revise the care plan as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of six residents (Resident 6) was free of significant medications errors when Resident 6 was administered 28 units (how insulin doses are measured) of Novolog Insulin 70/30 (a medication that lowers blood sugar and starts working within 15 minutes of administration) subcutaneously (under the skin) on 7/20/22 one hour before Resident 6 was served dinner and without ensuring Resident 6 ate dinner or had a snack after the insulin administration. As result, Resident 6, who did not eat dinner or had a snack after receiving insulin and on 7/20/22, felt shaky and had a blood sugar reading of 49 mg/dl [milligrams per deciliter] (normal range is between 70 and 100 mg/dl) at 9:30 p.m This failure placed Resident 6 at risk of fainting or becoming unresponsive due to hypoglycemia (low blood sugar). Findings: A review of Resident 6's Facesheet indicated she was admitted to the facility on [DATE] with diagnosis including Type 2 Diabetes (impairment of the body's ability to control blood sugar levels). A review of Resident 6's Physician Orders and Medication Administration Record (MAR) for July 2022 indicated the following order: NovoLOG Mix 70/30 Flex Pen Suspension Pen-Injector (70-30) 100 UNIT/ML [milliliters] (Insulin Aspart Prot & Aspart) [two types of insulin combined] Inject 28 units subcutaneously [under the skin using a small needle attached to the insulin pen] in the evening for DIABETES. BEFORE DINNER. IF B.G.[Blood Glucose] < 70 HOLD INSULIN, IF B.G. >450 CALL M.D. During an observation on 7/20/22, at 4:30 p.m., Licensed Nurse A administered 28 units of Novolog Mix 70/30 to Resident 6 subcutaneously. During an interview on 7/21/22, at 6 a.m., Licensed Nurse G stated Resident 6 reported feeling shaky the night before, on 7/20/22, at around 9:30 p.m. Licensed Nurse G stated he checked Resident 6's blood sugar and it was 49 mg/dl [milligrams per deciliter] (normal range between 70 and 100 mg/dl). During an interview on 7/21/22, at 7:55 a.m., the Director of Nursing (DON) stated Resident 6 refused dinner the previous evening, on 7/20/22, and had a low blood sugar reading later that night, of 49 mg/dl. The DON stated the low blood sugar was because she received insulin but did not eat afterwards. A review of Resident 7's Activities of Daily Living flowsheets (where staff document resident meal consumption) for July 2022 indicated no dinner or night snack consumption on 7/20/22. During an interview on 7/21/22, at 9:04 a.m., the Dietary Services Manager stated she was at the facility all day on 7/20/22 and stated dinner was served to residents starting at 5:30 p.m. During an interview on 07/26/22, at 9:40 a.m., Resident 6 was alert and oriented and stated she recalled the day her blood sugar was low the previous week. Resident 6 stated she did not remember if she ate dinner or not that night. Resident 6 stated that at around 9 p.m. she felt dizzy and shaky. Resident 6 stated she immediately knew her blood sugar was low. Resident 6 stated she called the nurse who checked her blood sugar level, and it was low. Resident 6 stated the nurse gave her juice and snacks and she recovered. During an interview and record review on 7/22/22, at 9:15 a.m., the Director of Nursing (DON) reviewed the PHYSICIAN ORDERS and MEDICATION ADMINISTRATION RECORD (MAR) of Resident 6. The DON confirmed Resident 6's order NovoLOG Mix 70/30 Flex Pen, 28 units subcutaneously before dinner, should be given within 15 minutes of dinner and staff should ensure Resident 6 eats food afterwards. During an interview on 7/22/22, at 10 a.m., the facility's Consultant Pharmacist (CP) stated Novolog Mix 70/30 is a mixture of short and long-acting insulin and has an onset of 15 minutes (meaning the medication starts producing its intended effects - lowering blood sugar - within 15 minutes of administration) and a peak period (where the medication effects are strongest) of 3-4 hours. The CP stated this medication should be given within 15 minutes of the resident eating, with the meal, or immediately after. The CP stated a meal should follow the administration of this medication, and that staff should ensure that a resident consumes food following the administration; otherwise, the resident will become hypoglycemic (with a low blood sugar). The CP stated a blood sugar of 49 mg/dl is considered low and places the resident at risk of fainting and becoming unresponsive. A review of the Novolog Mix 70/30 manufacturer's safety information indicated its onset is between 10 and 20 minutes, the peak activity is between 1.7 and 3.6 hours, and duration of action as long as 24 hours. The safety information further indicated: Administer [the medication] within 15 minutes before meal initiation . and Hypoglycemia is the most common adverse effect of . NovoLog® Mix 70/30 . Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life threatening or cause death. (https://www.novomedlink.com/diabetes/products/treatments/novologmix70-30.html). According to the Centers for Disease Control and Prevention (CDC), hypoglycemia occurs when the blood sugar drops below 70 mg/dl. Severe hypoglycemia occurs when the blood sugar drops below 54 mg/dl. (CDC, Low Blood Sugar, 2022, https://www.cdc.gov/diabetes/basics/low-blood-sugar.html). During an interview on 7/22/22, at 9:15 a.m., the DON stated the facility did not have a policy and procedure on insulin administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of six residents sampled for pressure ulcer (a localized injury to the skin and underlying tissue that occurs because of intense and prolonged pressure) review (Resident 199) received care, treatment, and services consistent with physician orders and professional standards of practice to prevent and treat pressure ulcers. For Resident 199, admitted on [DATE], bed-bound and immobile, with paralysis, admitted with a pre-existing Stage 3/Unstageable pressure ulcer (a wound where the whole skin is gone and the fat layer of tissue that underlines the skin is visible) on his coccyx (tail bone): (1) The facility failed to complete a risk assessment for developing pressure injuries (Braden Scale) upon admission for Resident 199. The first Braden Scale was completed on 7/12/22 (14 days after admission and after the resident had developed five pressure ulcers); (2) The facility failed to accurately assess Resident 199's skin when licensed nurses did not document all of Resident 199's pressure ulcers during skin assessments, with one skin assessment, completed one week after Resident 199's admission, indicating he had no pressure injuries or skin wounds; (3) The facility failed to timely develop an individualized care plan (a document instructing staff on how to care for the resident) for the prevention of pressure ulcers. The first pressure ulcer care plan was developed on 7/19/22 (22 days after admission) (after the resident had acquired 10 pressure ulcers); (4) The facility failed to develop an individualized care plan for prevention of pressure and treatment of pressure ulcers according to the resident's risk factors. The pressure ulcer care plan (7/19/22) did not include key interventions pertinent to the resident's situation, such as turning and repositioning the resident every two hours, use of heel protectors, use of wedge pillows for positioning and pressure relief, and off-loading heels; interventions that had been recommended by the wound specialist physician starting on 6/29/22; (5) The facility failed to timely implement standard interventions to prevent and treat Resident 199's pressure ulcers, such as turning and repositioning the resident every two hours, use of heel protectors, use of wedge pillows for positioning and pressure relief, and off-loading heels These interventions that had been recommended by the wound specialist physician starting on 6/29/22, with the key intervention of turning and repositioning Resident 199 only consistenly documented as implemented starting on 7/19/22 (22 days after admission); (6) The facility failed to timely implement a physician's order for deployment of a pressure redistributing mattress (low air loss mattress - LAL). The LAL was ordered on 6/29/22 but the facility provided it to the resident on 7/8/22 (10 days later), even though the facility had a LAL in stock at the time it was ordered; during this delay the resident developed five pressure ulcers; (7) The facility failed to timely and consistently implement physician orders for prevention and treatment of Resident 199 pressure ulcers. Treatments ordered to treat Resident 199's pressure ulcers and prevent new ones were not provided for up to 7 days after they had been ordered, and afterwards were not provided daily as ordered; (8) The facility failed to take steps to timely remove the resident's cervical collar (neck brace). The resident's transfer orders dated 6/28/22 indicated the cervical collar was to be removed on 7/4/22 (one week after admission), and the wound specialist physician recommended it removed on 7/7/22, but by 7/27/22 (30 days after admission) no steps were taken to remove the cervical collar. (9) The facility failed to develop and implement a system for monitoring and documenting the turning and repositioning of residents at risk for pressure ulcers, with documentation of the date and time and position the resident was turned. These failures resulted in Resident 199 developing a total of 10 pressure ulcers within two weeks of admission to the facility. Five pressure ulcers (one Stage I on the nose, one Stage II on the clavicle, one Unstageable on the left buttock, and one bilateral Deep Tissue Injury on each heel) were developed between within nine days of admission, from 6/29/22 to 7/7/22, and another five pressure ulcers (one Deep Tissue Injury on right leg, one Deep Tissue Injury on left leg, one Stage II and two Deep Tissue Injuries on the right buttock) were developed in the next five days, from 7/8/22 to 7/13/22. Findings: Review of the National Pressure Injury Advisory Panel revealed a pressure injury (also called a bedsore, pressure ulcer, pressure sore, or decubitus ulcer) is a localized injury to the skin and underlying tissue that occurs because of intense and prolonged pressure. Pressure injuries are classified into four stages, depending on the severity of the wound. A Stage 1 pressure injury is characterized by skin that is intact but with redness that is non-blanchable (does not turn white when pressed). A Stage 2 pressure injury shows a shallow ulceration (a break in the skin) with a red/pink wound bed, with only the superficial layers of the skin destroyed. A Stage 3 pressure injury indicates a wound where the whole skin is gone and the fat layer of tissue that underlines the skin is visible. A Stage 4 pressure injury is a wound where the both the skin and the fat tissue are destroyed, and it is possible to visualize the bones, muscles, ligaments and/or cartilage. (National Pressure Injury Advisory Panel, NPIAP Pressure Injury Stages, 2022, https://npiap.com/page/PressureInjuryStages) Review of theNational Pressure Injury Advisory Panel revealed there are also two additional types of pressure injuries: Unstageable Pressure Injures and Deep Tissue Injuries. An Unstageable Pressure Ulcer occurs when, as a result of unrelieved pressure on the skin, the whole skin is destroyed but the area is covered with slough or eschar (dead tissue), making it impossible to determine the exact stage without debridment (removal of the dead tissue). Once debrided, a Stage 3 or Stage 4 pressure injury will be revealed. A Deep Tissue Injury is also a skin wound resulting from unrelieved pressure. In a Deep Tissue Injury, there is no open wound or ulceration, but there is a non-blanchable are with a deep red and purple discoloration that indicates extensive damage to the underlying tissues, often evolving into a Stage 3 or Stage 4 pressure ulcer. (National Pressure Injury Advisory Panel, NPIAP Pressure Injury Stages, 2022, https://npiap.com/page/PressureInjuryStages). Review of the American Association of Family Physicians,revealed [Pressure] ulcers are difficult to resolve. Although more than 70 percent of stage II ulcers heal after six months of appropriate treatment, only 50 percent of stage III ulcers and 30 percent of stage IV ulcers heal within this period . and because skin wounds are colonized with bacteria, pressure ulcer place patients at risk of serious, life-threatening infectious complications such as bacteremia and sepsis (systemic infection), cellulitis (skin infection), endocarditis (heart infection), meningitis (spinal cord infection), osteomyelitis (bone infection), septic arthritis, and sinus tracts or abscesses. (American Association of Family Physicians, Pressure Ulcers: Prevention, Evaluation, and Management, Am Fam Physician. 2008;78(10):1186-1194). A review of Resident 199's Facesheet indicated he was admitted to the facility on [DATE] with a primary diagnosis of spinal cord injury and additional diagnoses including history of falling, generalized muscle weakness, bed confinement status and a Stage 3 pressure ulcer in the sacrum area (a large triangular bone in base of the spine). A review of Resident 199's SKILLED NURSING FACILITY TRANSFER ORDERS (Transfer Orders), dated 6/28/22, at 3:05 p.m., indicated Resident 199 was Bed bound due to paralysis from cancer lesions and needed frequent turnings to prevent ulcerations. The Transfer Orders also indicated Resident 199 had a cervical collar (a neck brace) which was to be worn through 7/4/22. A review of Resident 199's clinical record indicated a consultant report from WOUND MD (a wound care specialist physician on contract with the facility) dated 6/29/22, titled WOUND ASSESSMENT AND PLAN. This report consisted of an assessment of Resident 199's pre-existing coccyx pressure ulcer and contained treatment recommendations. The report indicated Resident 199 had an Unstageable Pressure Ulcer on his coccyx measuring 7 cm [centimeters] in length and 8.5 cm in width. The report contained the following TREATMENT ORDER: Daily cleanse the wound with normal saline or sterile water, then apply Santyl (an ointment that removes dead tissue), then cover wound with a moist dressing. The Report also indicated: Preventative Wound Recommendations: Air mattress . Type: low air flow . and Need low air loss mattress and off load and reposition [turn and reposition resident] per facility's protocol. No other pressure injuries were documented. A review of the facility's WEEKLY PRESSURE INJURY REPORT [a tally of all residents with pressure ulcers at the facility], dated for week of 6/29/22, indicated Resident 199 had one unstageable pressure ulcer in the coccyx, as documented in the WOUND MD assessment. The Report indicated orders given. No other pressure injuries were documented. Review of the American Association of Family Physicians (AAFP) revealed pressure reduction to preserve microcirculation is a mainstay of [pressure unjury] preventive therapy and the two most important interventions are frequent turning and repositioning and the application of pressure relieving devices to redistribute localized pressure: Patients who are bedridden should be repositioned every two hours and Pressure-reducing surfaces [such as low air loss mattress] lower ulcer incidence by 60 percent compared with standard hospital mattresses. (American Association of Family Physicians, Pressure Ulcers: Prevention, Evaluation, and Management, Am Fam Physician. 2008;78(10):1186-1194). A review of Wound Care Solutions revealed low air loss mattress is a mattress designed to prevent and treat pressure wounds. The mattress is composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time. This action relieves pressure under the body - particularly in parts with less padding, like hips, shoulders, elbows, and heels - and helps ensure proper air circulation, helping to prevent, manage, and treat the occurrence of pressure wounds. (Wound Care Solutions, How a Low Air Loss Mattress Can Keep Patients Wound Free, 2022, https://www.woundcareinc.com/resources/low-air-loss). A review of Resident 199's PROGRESS NOTES indicated note dated 7/1/22, at 3:51 p.m., titled SKIN ONLY EVALUATION, indicating: Resident has current skin issues and documented three Stage 2 pressure ulcers: one Stage 2 pressure injury on the left anterior neck measuring 3 cm (length) x 2 cm (width), one Stage 2 pressure ulcer on the left medial neck measuring 2 cm (length) x 1 cm (width) and one Stage II pressure ulcer on the left posterior (outer) neck measuring 1 cm (length) x 1 cm (width). There was no documentation of Resident 199's coccyx pressure ulcer or other pressure ulcers. A review of Resident 199's PROGRESS NOTES indicated note dated 7/4/22, at 3:50 a.m., titled SKIN ONLY EVALUATION, indicating no skin wounds, as follows: Skin warm and dry, skin color WNL [within normal limits], mucous membranes moist, turgor normal. No current skin issues noted at this time. A review of Resident 199's PROGRESS NOTES indicated note dated 7/5/22, at 1:41 a.m., titled SKIN ONLY EVALUATION, indicating Resident has current skin issues and documented four pressure ulcers: one Deep Tissue Injury on his left heel, two Deep Tissue Injuries, one on each buttock, and one Stage 2 pressure injury on his left clavicle (collar bone). There was no documentation of Resident 199's coccyx pressure ulcer or other pressure ulcers. A review of Resident 199's clinical record indicated a SECOND report from WOUND MD, dated 7/7/22, 8 days after the first report, titled WOUND ASSESSMENT AND PLAN. This report indicated Resident 199 had acquired five additional pressure ulcers, in addition to the pre-existing coccyx pressure ulcer, as follows: 1) COCYX Pressure Ulcer, Unstageable, Wound Measurements: 8 cm length x 6.6 cm width. Date of onset: 6/29/22. [Treatment order unchanged]. 2) LEFT CLAVICLE Pressure Ulcer related to medical device, Stage 2, wound measurement: 0.7 cm length x 0.5 cm width x 0.1 Depth. Date of onset: 7/7/22. TREATMENT ORDER: Daily cleanse wound with normal saline or sterile water, apply medihoney (a healing ointment) then cover wound with foam dressing for pad/protection. Need to discuss with neurosurgery clinic ASAP (as soon as possible) about collar causing wound and see if safe to be removed now. If it cannot be removed, need to ask neurosurgery about their recommendation on how to prevent further skin injury. 3) LEFT BUTTOCK Pressure Ulcer, Unstageable, Wound Measurements: 3.5 cm length x 1 cm width. Date of onset: 7/7/22. TREATMENT ORDER: Daily cleanse the wound with normal saline or sterile water, then apply Santyl, then cover would with a moist dressing. The Report also indicated: Preventative Wound Recommendations: Air mattress . Type: low air flow . 4) LEFT HEEL Deep Tissue Pressure Ulcer, Wound Measurements: 4.5 cm length x 4.5 cm width. Date on onset: 7/7/22. TREATMENT ORDERS: Leave open to air and off load heel (place pillow, foam, soft boots or any other material that redistributes the pressure around the heels). 5) RIGHT HEEL Deep Tissue Pressure Ulcer, Wound Measurements: 2.5 cm length x 1.5 cm width. Date on onset: 7/7/22. TREATMENT ORDERS: Leave open to air and off load heel. 6) NOSE Pressure Ulcer Stage 1, Wound Measurements: not listed. Date on onset: 7/7/22. TREATMENT ORDERS: Off load area and do not use glasses if able for 7 days. Recommend eye clinic evaluation with new glasses that would not cause more pressure to the area . A review of the facility's WEEKLY PRESSURE INJURY REPORT, dated for week of 7/7/22, indicated Resident 199 had six pressure ulcers, as documented in the second WOUND MD report dated 7/7/22. A review of Resident 199's PROGRESS NOTES indicated note dated 7/11/22, at 00:28 a.m., titled SKIN ONLY EVALUATION, indicating Resident has current skin issues and noted two pressure ulcers: an Unstageable Pressure Ulcer on Left Heel and a Deep Tissue Pressure Injury on buttock. A review of Resident 199's PROGRESS NOTES indicated note dated 7/12/22, at 3:21 p.m., titled SKIN ONLY EVALUATION, indicating Resident has current skin issues and noted two pressure ulcers: Stage 3 Pressure Ulcer on Coccyx and Stage 2 Pressure Ulcer on Left Clavicle. A review of Resident 199's clinical record indicated the first assessment of Resident 199's risk for pressure ulcers, the BRADEN SCALE for Predicting Pressure Ulcer Risk, was completed on 7/12/22, 14 days after his admission, and indicated Resident 199 had a score of 9, meaning he was at a VERY HIGH RISK of developing pressure ulcers. The 7/12/22 Braden Scale indicated Resident 199's sensory perception (the ability to respond meaningfully to pressure-related discomfort) was very limited; skin moisture (the degree to which skin is exposed to moisture) was very moist; activity (degree of physical activity) was confined to bed, mobility was completely immobile (does not make even slight changes in body or extremity position without assistance); nutrition was probably inadequate; and friction was problem (requires moderate to maximum assistance in moving .requires frequent repositioning with maximum assistance .). A review of Resident 199's clinical record indicated a THIRD report from WOUND MD, dated 7/13/22, and titled WOUND ASSESSMENT AND PLAN. This report indicated the presence of 11 pressure ulcers, five more than present during the SECOND report dated 7/7/22, as follows: 1) COCYX Pressure Ulcer, Unstageable, Wound Measurements: 7.5 cm Length x 7.5 cm. [Present upon admission - Noted on First and Second Report - Treatment orders unchanged]. 2) LEFT CLAVICLE Pressure Injury related to Medical Device, Stage 2, Wound Measurement: 0.5 cm Length x 0.1 cm Width. [Noted on Second Report - Treatment orders unchanged]. 3) LEFT BUTTOCK Pressure Ulcer, Unstageable, Wound Measurements: 1.5 cm Length x 1 cm Width. [Noted on Second Report - Treatment orders unchanged]. 4) LEFT HEEL Deep Tissue Pressure Ulcer, Wound Measurements: N/A. [Noted on Second Report - Treatment orders unchanged]. 5) RIGHT HEEL Deep Tissue Pressure Ulcer, Wound Measurements: 2.5 cm Length x 1.5 cm Width. [Noted on Second Report - Treatment orders unchanged]. 6) NOSE Pressure Ulcer Stage 1, Wound Measurements: N/A. [Noted on Second Report - Treatment orders unchanged]. 7) RIGHT LATERAL LEG Deep Tissue Pressure Ulcer, Wound Measurements: 6 cm length x 3 cm width. Date of onset: 7/13/22. TREATMENT ORDERS: Daily cleanse wound with normal saline or sterile water, apply Santyl and cover with moist gauze and apply foam dressing to the area for pad/protection. Off load and reposition per facility's protocol. Preventative Wound Recommendations: Air mattress . Type: low air flow . 8) LEFT LATERAL LEG Deep Tissue Pressure Ulcer, Wound Measurements: 4 cm length x 3 cm width. Date of onset: 7/13/22. TREATMENT ORDER: Daily cleanse wound with normal saline or sterile water, apply Santyl and cover with moist gauze and apply foam dressing to the area for pad/protection. Off load and reposition per facility's protocol. Preventative Wound Recommendations: Air mattress . Type: low air flow . 9) RIGHT BUTTOCK (DISTAL) Pressure Ulcer Stage 2, Wound Measurement: 2 cm length x 1.5 cm width x 0.1 cm depth. TREATMENT ORDER: Daily apply foam dressing to the area for pad/protection. Must off load and reposition per facility's protocol. and Preventative Wound Recommendations: Air mattress . Type: low air flow . 10) RIGHT BUTTOCK (PROXIMAL INNER) Deep Tissue Pressure Injury, Wound Measurement: 2 cm length x 2 cm width. TREATMENT ORDER: Daily apply foam dressing to the area for pad/protection. Must off load and reposition per facility's protocol. and Preventative Wound Recommendations: Air mattress . Type: low air flow . 11) RIGHT BUTTOCK (PROXIMAL LATERAL) Deep Tissue Pressure Injury, Wound Measurements: 5.5 cm Length x 2.5 cm Width. TREATMENT ORDER: Daily apply foam dressing to the area for pad/protection. Must off load and reposition per facility's protocol. and Preventative Wound Recommendations: Air mattress . Type: low air flow . A review of the facility's WEEKLY PRESSURE INJURY REPORT, dated for week of 7/13/22, indicated Resident 199 had 11 pressure ulcers, as documented in the WOUND MD'S report dated 7/13/22. A review of Resident 199's PRIMARY CARE PHYSICIAN progress note, dated 7/16/22, indicated [Resident] has decubital ulcer on left clavicular region from hard c spine collar . Several decubital ulcers on coccyx region and left heal (sic) . Must rotate him every 2 hours to prevent these ulcers. During an observation and interview on 7/18/22, at 10:50 a.m., Resident 199 had a cervical collar was lying on his back in his room. Resident 199 stated he could not move his legs or reposition himself in bed without assistance. During an interview on 7/27/22, at 8:24 a.m., the Director of Nursing (DON) stated Resident 199 was admitted to the facility on [DATE] from the hospital and had one Stage III pressure ulcer on his coccyx area (tailbone). The DON stated all the other pressure ulcers documented in his clinical record had been acquired at the facility. The DON stated Resident 199 was immobile, completely dependent on staff assistance for movement, and was at high risk for developing pressure ulcers. The DON was asked for the dates and scores of Resident 199's Braden Scale for Assessing the Risk of Pressure Ulcers evaluations. The DON reviewed Resident 199's record and stated the first Braden Scale for Resident 199 was completed on 7/12/22 and indicated a score of 9, meaning the resident was at a VERY HIGHT RISK of developing pressure ulcers. During the same interview on 7/27/22, at 8:24 a.m., the DON was asked, given Resident 199's risk for developing pressure ulcers, what pressure ulcer prevention care plans had been developed for him. The DON reviewed Resident 199's record and stated two pressure ulcer care plans were created for Resident 199, both on 7/19/22. The first care plan indicated, Resident has potential/actual impairment to skin integrity . and Resident will have no complications related to pressure ulcers on coccyx, clavicle, buttocks and heels. This care plan listed the following interventions: encourage good nutrition, monitor pressure ulcers, use draw sheets to lift/move resident, use caution during transfers, treatment documentation, and resident needs pressure relieving mattress. The second care, also created 7/19/22, indicated Documented Pressure Ulcer and Management of Pressure Ulcer. This care plan listed the following interventions: educate resident about skin care to prevent skin breakdown, encourage resident to frequently shift weight, evaluate skin, evaluate ulcer characteristics, monitor bony prominences for redness, and monitor nutritional status. No other interventions were listed. During the same interview on 7/27/22, at 8:24 a.m., the DON was asked what could have been done to prevent Resident 199's pressure ulcers. The DON stated two key preventative measures for Resident 199 were the use of a low air loss mattress and turning and repositioning Resident 199 at least every two hours. The DON was asked if Resident 199 had been given on a low air loss mattress. The DON stated yes. The DON was asked when. The DON reviewed Resident 199's physician orders and stated the low air loss mattress order was entered on 7/8/22 (10 days after WOUND MD recommended it), but stated she was unsure of the actual day the low air loss mattress was deployed. The DON stated the Director of Staff Development (DSD) knew. During a concurrent interview, the DSD stated she entered the order for Resident 199's low air loss mattress on 7/8/22 and stated the low air loss mattress was given to him at the same time of the order, because we have them [low air loss mattresses] in stock here [at the facility]. During the same interview on 7/27/22, at 8:24 a.m., the DON was asked if Resident 199 had been turned and repositioned every two hours. The DON stated yes. The DON was asked to provide documentary evidence this intervention had been implemented. The DON stated staff did not usually document turning and repositioning of residents at risk for pressure ulcers. The DON stated the facility did not have a system for tracking when and how residents at risk for pressure ulcers are turned and repositioned. The DON stated Resident's 199's Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained documentation of turning and repositioning. The DON asked the Medical Records Director to print Resident 199's MAR and TAR for June and July 2022. A review of the MAR June and July 2022 indicated documentation of turning and repositioning Resident 199 every two hours starting on 7/20/22 (23 days after his admission). This documentation consisted of a check mark three times a day in which the staff attested the resident was turned and repositioned every two hours. It did not contain documentation of the specific times Resident 199 was turned and repositioned or the specific side the resident was placed on (left, right, back). According to the AAFP, The basic components of pressure ulcer management are reducing or relieving pressure on the skin, debriding necrotic tissue, cleansing the wound, managing bacterial load and colonization, and selecting a wound dressing. (American Association of Family Physicians, Pressure Ulcers: Prevention, Evaluation, and Management, Am Fam Physician. 2008;78(10):1186-1194). During the same interview on 7/27/22, at 8:24 a.m, the DON was asked for documentary evidence that the WOUND MD's treatments and interventions had been provided to Resident 199. The DON stated the treatments were documented in Resident 199's MAR and TAR. During a concurrent interview, the Medical Records Director was asked for a copy of Resident 199's MAR and TAR for June and July 2022. A review of these records indicated the WOUND MD orders for the treatment of Resident 199's pressure ulcers were untimely implemented, with delays of up to eight days, and were implemented inconsistently (daily orders not implemented on all days), as follows: WOUND MD's order for daily treatment of Resident 199's coccyx pressure ulcer, dated 6/29/22, was implemented starting on 7/1/22, but with no documentation in the TAR the treatment was provided on 7/3, 7/4, 7/10, 7/11, 7/14, 7/17, 7/18, 7/21, 7/24 and 7/25/22 (treatment delayed by up to two days and not provided on 30% of the days). WOUND MD's order for daily treatment of Resident 199's clavicle pressure ulcer, dated 7/7/22, was implemented starting on 7/15/22, but with no documentation it the TAR the treatment was provided 7/17, 7/18, 7/21 and 7/26 (treatment delayed by up to eight days and not provided on 40% of the days). WOUND MD's order for daily treatment of Resident 199's heel pressure ulcers (left and right), dated 7/7/22, was implemented starting on 7/15/22, but with no documentation the treatment was provided on 7/17, 7/18, 7/21 and 7/24 (treatment delayed by up to eight days and not provided on 30% of the days). WOUND MD's order for daily treatment of Resident 199's bilateral legs pressure ulcers (two wounds), dated 7/7/22, was implemented starting on 7/15/22, but with no documentation the treatment was provided on 7/17, 7/18, 7/21 and 7/25 (treatment delayed by up to eight days and not provided on 30% of the days). WOUND MD's order for daily treatment of Resident 199's buttock pressure ulcers (four wounds), dated 7/7/22, was implemented starting on 7/15/22, with no documentation the treatment was provided on 7/17, 7/18, 7/21, and 7/25 (treatment delayed by up to eight days and not provided on 30% of the days). WOUND MD's order for daily treatment of Resident 199's nose pressure ulcer, dated 7/7/22, was implemented starting on 7/14/22 (treatment delayed by up to seven days). During the same interview on 7/27/22, at 8:24 a.m., the DON stated Resident 199's clavicle pressure ulcer had been caused by his cervical collar. The DON was asked why the cervical collar had not been removed. The DON stated it was not removed because the facility had been unable to obtain a neurology consult and have an x-ray done to ensure it was safe to remove it. The DON stated there were no neurology specialists available in the area and no mobile x-ray services able to come to the facility. A review of facility policy and procedure titled PRESSURE INJURY PREVENTION, revised September 1, 2020, indicated: A risk assessment for developing pressure injuries will be completed upon admission . Regardless of the risk score, the Licensed Nurse will develop an individualized care plan for the Resident's risk factors . The Licensed Nurse will develop a care plan that contains interventions for Residents who have risk factors for developing pressure injuries or for those Residents who have pressure injuries and [are] at risk of developing additional pressure injuries. The care plan will be initiated on admission and updated as necessary. The nursing staff will implement interventions identified in the care plan which may include, but are not limited to, the following . pressure redistributing devices for bed and chair . repositioning and turning .heel and elbow protectors . off-loading pressure from heels .use of (wedge) pillows for positioning and pressure relief . A review of facility policy and procedure titled SKIN AND WOUND MANAGEMENT, revised January 1, 2022, indicated: Facility staff will take appropriate measures to prevent and reduce the likelihood that residents will develop pressure ulcers and other skin conditions. The Licensed Nurse will complete the Braden Scale for predicting pressure score risk upon admission . A Licensed Nurse will complete the Weekly Skin Evaluation. The Licensed Nurse will develop a Care Plan to identify interventions to prevent the development of pressure ulcers. Treatments for skin problems, wounds, and non-pressure ulcers will be assessed and documented by a Licensed Nurse. A review of facility policy and procedure titled PRESSURE INJURY AND SKIN INTEGRITY TREATMENT, revised August 12, 2016, indicated: Treatments to pressure injuries or other skin integrity problems will be ordered by the physician. Treatments administered will be documented on the Treatment Administration Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision to reduce the risk of falls for one of four sampled residents at risk of falls (Resident 58). This failure likely contributed to Resident 58 having five falls in a three-month period from 1/1/2019 to 4/1/2019, which resulted in multiple unwitnessed falls, one with injury. Findings: During an interview with Resident 58 alone in her room on 04/09/19 at 3:55 p.m.: Have you had any falls? I did Can you tell me what happened? I don't remember During an interview with Unlicensed Staff P on 04/09/19 at 4:16 p.m. He confirmed he was working on 3/8/19, but stated he was not assigned to the Resident 58 when she fell. She has a self-release seatbelt, also a mat alarm on her wheelchair, a mat alarm in her bed, padded floor mat, room close to the nurses' station to hear the alarms. During a review of the clinical record for Resident 58, the annual MDS dated [DATE], Sections A, G, H and J indicated Resident 58 was independent with bed mobility, supervision with limited assistance with transfers, walking in room, locomotion off unit. ADL support provided. Resident 58 is not steady, but able to stabilize without staff assistance. Resident 58 using wheelchair. Resident is occasionally incontinent, Resident had two or more falls with no injury. During a review of the clinical record for Resident 58, the quarterly MDS dated [DATE], Sections A, G, H and J indicated Resident was limited assistance with bed mobility. Supervision and limited assistance with transfers. Limited assistance with walking in room. Limited assistance with toilet use. Resident 58 is not steady, but able to stabilize without staff assistance. Resident 58 uses a wheelchair. No urinary toileting program. Resident 58 is always continent. No bowel toileting program. Resident had two or more falls with no injury. Resident had one fall with injury. During a review of the clinical record for Resident 58, the significant change MDS dated [DATE], Sections A, C, G, H and J indicated Resident needs limited assistance with bed mobility and extensive assistance with transfers. Resident 58 needs extensive assistance walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, personal hygiene. Resident 58 is not steady, only able to stabilize with staff assistance. Resident uses walker and wheelchair. Resident is always continent. No toileting program. Resident had two or more falls with no injury. Resident had one fall with injury. Resident had one fall with major injury. During interview with Unlicensed Staff Q on 04/10/19 at 08:24 a.m. she stated: I have worked here for one year, I am a traveler. I went into her room and Resident 58 was sitting on her bed crying, she said she had just fallen in the bathroom. I went to the nurse, told her, Licensed Nurse R went in to assess her and they sent Resident 58 out. Resident 58 has a bed alarm that she has had the whole time I've been here, because she has always been a fall risk. Resident 58 has a Tab alarm(The use of bed and chair alarms proliferated in the 1990s, when physical restraints were banned, and are intended to go off when a resident's weight shifts, indicating they may be trying to stand without assistance.) on wheelchair. The hard part is Resident 58 is able to turn off her Tab alarm on wheelchair. Resident 58 turns off her alarm, we repeatedly remind her to use her call-light, but she is non-compliant with that. Resident 58 gets upset when we try to help her. Resident 58's room has been by the nurses' station, her roommate is a fall risk also. Resident 58's roommate's alarm would go off and it would concern Resident 58. When her roommate gets agitated, we encourage Resident 58 to join us in the dining room for coffee so we can keep an eye on her. During an interview on 4/10/19 at 08:53 a.m. with Lisensed Nurse R. She confirmed she was the nurse for Resident 58 on 3/8/19. She stated that Resident 58 was up in wheelchair, she self transfered back into bed, we heard a noise and we ran in there. One of the CNA's found her and called me into the room. Resident 58 is so forgetful, she has been on bed and chair alarms for months/years. I asked her what were you doing? Resident 58 stated she was going to bed. Resident 58 is a quick little thing. Resident 58 was complaining of pain in her right hip. When I got in there, Resident 58 was sitting on the edge of the bed. The aide told me she had gotten up. Resident 58 has had so many falls. I called 911 and the MD. When Resident 58 came back later that day, we tried to keep her on bedrest using a bedpan, that didn't work because she kept getting up. Resident 58 had a bed alarm on. Resident 58 was a two person assist for a couple of days. We gave her multiple reminders, she couldn't remember. Then she was a one person assist, she had a self-releasing seatbelt, now she has a pull tab, she can turn it off. We run in there. We do walkby checks. During a review of the clinical record for Resident 58, the record indicated: Resident with multiple falls 3/8/2019, 2/4/2019, 1/25/2019, 1/18/2019, 1/1/2019. Resident with vascular dementia. During review of the clinical record for Resident 58, the Resident admission assessment dated [DATE] indicates Resident is alert and oriented, incontinent and uses a walker. Resident needs supervision with ambulating and transfers. During review of the clinical record for Resident 58 for IDT notes dated: 3/8/19 fall, which indicated at 0615 resident was sitting on her bed and indicated she had fallen a few minutes prior. Transferred to Redwood Memorial Hospital for eval and treat. 2/5/19 fall, hx of falls. Resident was getting up from toilet and foot slipped. Resident fell backwards and hit head on sink. Nurse was present but unable to prevent fall. 1/28/2019 (fall 1/25/19) at 1350 Resident was standing up from wheelchair and lost balance and fell back and landed on her bottom and hit posterior head. 1/2/2019 Quarterly review: No mention of falls During review of the clinical record for Resident 58, the Post Fall Huddle dated11/15/18 indicated an unwitnessed fall on 11/15/18 at 0820 a.m. During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 1/1/19 indicated fall in room at 0700 a.m. During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated no pain, no injury. During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 1/18/18 indicated fall in room at 1845 p.m. During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated Resident had pain in her head 10/10, fall was unwitnessed During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated Resident had pain posterior head 6/10, Resident found on floor. During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 1/25/19 indicated Resident had a fall in her room at 1350 p.m. Refer to RNA for strengthening. During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated Resident had pain in the right occipital area During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 2/4/19 indicated Resident fell in bathroom at 0730 a.m. Currently on RNA program During review of the clinical record for Resident 58, the Post Fall assessment dated [DATE] indicated Resident had pain in Right Hip and Right Leg During review of the clinical record for Resident 58, the Therapy Post Fall Screen dated 3/8/19 indicated Resident fell in her room at 0615 a.m. Resident continues to self-transfer and not use call light. Resident with vascular dementia. During review of the clinical record for Resident 58, the SBAR Communication Form, dated 1/18/2019 indicates unwitnessed fall in bathroom on 01/18/19. During review of the clinical record for Resident 58, the SBAR Communication Form, dated 1/1/19 indicates fall, Resident turns off bed alarm During review of the clinical record for Resident 58, the SBAR Communication Form dated 2/4/19 indicates the Resident fell in the bathroom. During review of the clinical record for Resident 58, the SBAR Communication Form dated 3/8/19 indicates the Resident stated she had fallen, sent to Redwood Memorial Hospital. During review of the clinical record for Resident 58, the Nurses Notes, dated 1/28/19 night shift indicated s/p fall day 3 Neuro checks WNL. Resident continues to self-transfer despite numerous reminders to use call light and wait for assistance. During review of the clinical record for Resident 58, the Nurses Notes dated 2/4/19 at 2200 p.m. indicates witnessed fall this a.m. During review of the clinical record for Resident 58, the Nurses Notes dated 3/8/19 indicated Resident fell in her room. Resident sent to ER. Resident returned to facility with fractured hip. During review of the clinical record for Resident 58, the report from Redwood Memorial Imaging Ground level fall with right hip pain Impression: Moderately comminuted right greater trochanteric fracture. Dated 3/8/2019. During review of the clinical record for Resident 58, the Fall Risk Care Plan dated 3/19/2019. Dementia Care Plan dated 3/19/2019. MD order to start RNA program dated 1/21/19 for 3X week transfer training, ambulate with FWW. MD order ok to place seat belt alarm on wheelchair for increase safety measures. Understanding restraint use 12/1/14. informed consent 3/15/18 self-releasing seat belt in wheelchair. During interview on 04/10/19 at 11:04 a.m. with the Director of Nurses stated: Alarms, we continually remind her call bell is in her reach, fall mat in place, every 2 hours needs assistance, more often most of her falls are transferring from bed to wheelchair, wheelchair to bed, going to bathroom by herself. Resident 58 never asks for assist. She doesn't remember. Resident 58 came from a place in Fresno that was closed, mostly dementia, psych dx. Resident 58 has a friend here, who came with her. Resident 58 has severe dementia. We have her as close to the nurses' station as we can, it's an all hands on deck. We had her on the RNA program for strength training and balance. We have done every 2 hours. But could not state when and documentation requested to support. She hasn't had any med changes. I would have to go back and look. Resident 58 has a self-releasing seatbelt, we encourage her to go to the dining room for activities. During observation on 04/10/19 at 11:35 a.m. Resident 58 in bed in room, alone, no one in hallway. 04/10/19 at 12:00 p.m. Resident 58 got up and wheeled out to dining room. No one assisted resident. When Resident got to dining room, a CNA asked if she needed assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. During an initial pool sample selection interview, on 2/26/18, at 9:06 a.m., Resident 16 stated, they're always short with people. Resident 16 stated she had to wait up to an hour before staff would answer the call light because they did not have the help you need. Resident 16 stated, If you can't get into the toilet, it's bad, you have to do it in your pants. No words to describe it. Put yourself where you're laying and you can't move. You have to go; you're trying to hold it. You're embarrassed. Resident 16 stated if you were already sitting in the toilet, you have to wait until someone comes. During a review of the clinical record for Resident 16, the Minimum Data Set (Resident assessment tool) dated 12/11/7, indicated Resident 16 needed an extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer and toileting. 4a. During an observation on 2/26/18 at 1:15 p.m., Resident 5 was in bed in a light weight hospital gown, which was not tied and caused her upper chest to be fully exposed. Resident 5 was positioned at approximately a 45 degree angle for lunch. Resident 5 was on a puree diet, which was over her bed, but no one was assisting Resident 5 with her meal and food particles were all over her. No straw was in her glass per physician's order. During a concurrent observation and interview on 2/28/18 at 2:10 p.m., Resident 5 was feeding herself a pureed diet. Resident 5's was positioned at a 45-degree angle while eating, napkin was not in place and food was all over Resident 5's clothes and blankets. There was no staff supervising Resident 5 while she was eating her meal. Resident 5's breathing sounded a little raspy after meal. Licensed Staff H stated Resident 5 did need assistance. Licensed Staff H stated Resident 5 did have a bib, but she had pulled it off and it was under her covers. Licensed Staff H stated the certified nursing assistant (CNA) would go between Resident 5 and Resident 38, but there was not enough staff to assist residents who were eating in their room and in the assisted dining room at the same time. Licensed Staff H stated the CNAs assisted the residents in the assisted dining room first and then the residents who wanted to eat in their room. A review of Resident 5's Physician Orders, dated 12/12/16, and Medication Administration Records (MAR), dated 1/18 and 2/18, indicated Resident 5 was on swallowing precautions and needed a straw for thin liquids. Resident 5's Annual MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 12/5/17, indicated Resident 5's cognitive skills for daily decision making was severely impaired (never/rarely made decision), the range of motion of upper right extremity (limb) and both lower extremities were impaired, and Resident 5 had a swallowing disorder: loss of liquids/solids from the mouth when eating or swallowing. During an interview on 3/06/18 at 3:37 p.m., Licensed Staff BB was asked why Resident 5's Quarterly MDS for 9/5/17 and Annual MDS for 12/5/17 ADLs (Activities of Daily Living) for eating indicated Resident 5 was a Set-up Help Only when Resident 5's Resident Care Plan - Nutrition -Swallowing, indicated Resident 5's swallowing interventions included staff to monitor Resident 5 for signs and symptoms of aspiration: shortness of breath, wheezing (whistling sound produced in the respiratory airways during breathing), coughing ., instruct resident to swallow after each bite, instruct/cue resident to chin tuck (tip head forward), and elevate head of bed minimum of 90 degrees during meals and for 30 minutes after, etc. Licensed Staff BB stated Resident 5's MDS should have been coded as One Person Assistant. When asked what she looked at before coding, Licensed Staff BB stated she reviewed the resident's medical records including the physician's History and Physical, Nurse's Progress Notes, and Medication Administration Record, and talked to nursing staff and to the resident, if they were able to communicate A review of Resident 5's Resident Care Plan - Nutrition-Swallowing Impairment, dated 12/17/18, indicated swallowing interventions included monitor for signs and symptoms of aspiration: shortness of breath, wheezing (whistling sound produced in the respiratory airways during breathing), coughing ., instruct resident to swallow after each bite, instruct/cue resident to chin tuck (tip head forward), and elevate head of bed minimum of 90 degrees during meals and for 30 minutes after. These care plan interventions were not being followed. 4b. During an observation on 2/26/18 at 1:19 p.m. Resident 38 was eating her pureed lunch unassisted in bed. Resident 38 was positioned at a 45 degree angle and leaning to the right side. Resident 38's overbed table was positioned to the side of the bed, so Resident 38 could not reach her tray. Resident 38's plate of pureed beans and taco casserole was uncovered and no one came to assist her. Resident 38 was holding a bowl of pureed food and was scooping the food out with her hand. Resident 38 was still in her hospital gown and there was food all over her chest. Resident 38 did have a sipping cup, but she also had a non-adaptive glass filled to the top and out of reach. During an observation on 2/28/18 at 1:55 p.m., Resident 38 was having her lunch in bed unassisted. Resident 38 was holding her sipping cup and trying to drink from it, but she was having difficulty bring the cup to her mouth. Resident 38 had no napkin on her and milk was dripping all over her. Resident 38's pureed lunch tray was on her overbed table, but Resident 38 had slid down in the bed and could not reach her lunch tray. During a concurrent observation and interview on 2/28/18 at 2:00 p.m., Licensed Staff H was asked to see Resident 38's position in bed as Resident 38 attempted to feed herself lunch. Licensed Staff H stated Resident 38 was not positioned correctly in bed for lunch in order for Resident 38 to reach her meal tray. Licensed Staff H stated Resident 38 was down to low in the bed. Licensed Staff H stated Resident 38's daughter had requested Resident 38 attempt to feed herself first. Licensed Staff H stated Resident 38 did use her fingers to feed herself and Resident 38's daughter was aware. Licensed Staff H stated Resident 38 should have been assisted with her lunch, but the CNA had to assist the residences in the assisted dining room first and then assist the residences eating in their room. Resident 38 was trying to feed her stuffed monkey the sipping cup full of milk. During an interview on 3/7/18 at 8:45 a.m., Confidential X stated the facility knew Resident 38 was total care and needed assistance with eating. Confidential X stated she/he never said it was okay for Resident 38 to use her fingers to scoop out food from a bowl. Confidential X was very upset and sounded very sad because she/he did not live near the facility and was relying on the staff to take good care of Resident 38. Confidential X stated Resident 38 was a total assist. Confidential X stated Resident 38 had severe dementia, so one did not know from one minute to the next if Resident 38 could feed herself or needed to be assisted. Confidential X stated someone really needed to supervise Resident 38 with her meals. Confidential X stated Resident 38 needed total assistance with hygiene, positioning, meals Confidential X stated Resident 38 could not even turn herself. During an interview on 3/7/18 at 9:15 a.m., DON stated Resident 38 should have been positioned upright for her meals, but Resident 38's daughter wanted her to be independent with her meals as much as possible. DON stated it would be better if Resident 38 could have finger foods, but she was on a pureed diet. DON was asked if she thought there was a dignity/safety issue regarding Resident 38 using her fingers to scoop pureed food out of a bowl. DON stated the CNA did make rounds to see if Resident 38 was okay with feeding herself. DON did not see a dignity issue with Resident 38 scooping food out of a bowl with her fingers. DON did not see a safety issue with Resident 38 eating her meals unassisted even after it was brought to her attention Resident 38 had been trying to eat her lunch unassisted on 2/26/18 while positioned at a 45 degree angle, Resident 38's plate had been uncovered, but her overbed table was out of reach, no CNA was in the hallway because the CNAs were in the assisted dining room assisting residents, and Resident 38 was care planned for needing Total Meal Assist. Resident 38's admission MDS, dated [DATE], indicated Resident 38's cognitive skills for daily decision making was severely impaired (never/rarely made decision), and Resident 38 had a swallowing disorder: loss of liquids/solids from the mouth when eating or swallowing. A review of Resident 38's Resident Care Plan - Activities of Daily Living, dated 1/11/18 and Resident Care Plan - Nutrition and Hydration, dated 1/15/18, indicated Resident 38 needed assistance with eating and bed mobility, decreased food intake, history of weight loss, dysphagia, cognitive impairment, and decreased feeding skills. Interventions for Resident 38 included total meal assist, encourage sipping cup, offer fluids frequently, and encourage oral fluids and eating at each meal. Total meal assist was not occurring. 2b. During a confidential group interview on 2/27/18, at 11:30 a.m., regarding call light wait time, one of nine attended residents stated sometimes he had to wait for a long time. Another resident stated it depended on what they needed. The resident stated one CNA (certified nursing assistant) per hall, some CNAs helped, but some would not. 3. During a concurrent observation and interview on 2/26/18, at 8:32 a.m., in Resident 47's room, Resident 47 stated he needed help to open the window curtain. Resident 47 squeezed the call bell (a ball like call bell) a total of five times, but the call light was not on. Resident 47 stated he could not move his right arm and hand, so he used his left hand to squeeze the call bell. Unlicensed Staff C walked by the hallway and was called into Resident 47's room. Unlicensed Staff C stated Resident 47 might have not pressed the call bell hard enough. Unlicensed Staff C opened the window curtain for Resident 47. Unlicensed Staff C did not assess or educate Resident 47 on call bell use. Resident 47's MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/1/18, revealed Resident 47's BIMS (brief interview for mental status) score was 15, which indicated Resident 47 was cognitively intact. During a concurrent observation and interview on 3/1/18, at 9:57 a.m., in Resident 47's room with Licensed Staff D regarding the call bell, Resident 47 squeezed multiple times and squeezed hard that the call bell (a ball like call bell) was dented, but the call light was not on. Resident 47 stated he would like to use the call bell for assistance. Licensed staff D tested the call bell and call light was on. Licensed Staff D stated the call bell was working, but Resident 47 was not able to use it correctly due to lack of hand coordination. The Maintenance Director came in and tested the call bell. The Maintenance Director stated he had to press down the call bell quickly to make it work. He stated if the resident pressed down slowly, it would not work. During an interview on 3/1/18, at 10:10 a.m., Licensed Staff D stated Resident 47 could use the call bell, but she did not know when his last time used the call bell. When asked how would Resident 47 able to get help when staff was not in his room, Licensed Staff D stated Resident 47 would called out loud, which could be heard in the nurse station. Licensed Staff D stated Unlicensed Staff C should have reported to her (Licensed Staff D) and she should have reported to the Maintenance Director to change the right type of call bell for Resident 47. Licensed Staff D stated they had a few different types of call bell. Upon request for facility policy and procedure, the facility provided the Resident [NAME] of Right, dated 05/11, indicated .Patients shall have the right .to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs . Based on observation, interviews, and facility document review, the facility failed to ensure resident's rights were protected for five of 17 sampled residents (Resident 221, 47, 38, 16, and 5) and two confidential residents when: 1. Facility did not provide assistive devices to Resident 221 to maintain correct position after a surgery and activity items to dull or distract from the noise level in the facility, which resulted in Resident 221 suffering from the terrorizing noise level and not receiving a grabber (picker-upper) to avoid bending; 2. Staff did not respond to call lights in a timely manner, which resulted in a) residents not receiving assistance or care timely, b) Resident 221 urinating on herself, being humiliated, falling on her own urine, and requesting early discharge because she was in fear for her life, and c) Resident 16 feeling bad and embarrassed beyond words; 3. Staff did not assess or educate Resident 47 on call light use, which resulted in Resident 47 not being able to use the call light for assistance, potentially causing falls, injuries, or embarrassment; and 4. Staff did not assist Resident 5 and 38 for meals, which resulted in residents having difficulty in feeding themselves, spilling food over their clothing, and not being positioned properly for meals. These failures had negatively impacted residents' psychosocial well-being and quality of life. Findings: 1-2. During an interview on 3/6/18 at 10:00 a.m., Resident 221 (post-op right hip arthroplasty, a surgical procedure to restore joint functions) stated she left the facility prior to end of insurance coverage because she felt her life was in danger. Resident 221 stated the facility housed a majority of seniors who could not care for themselves, but were not taken care of by the staff. Many of the wheelchair residents had alarms on their wheelchairs. When they moved, or stood, these alarms went off, but no staff came to address the alarms, or check on the residents. The noise level was terrorizing. Resident 221 stated she witnessed other residents fall, and fell herself one night. When asked how she fell, Resident 221 stated she needed to go to the bathroom, and placed the call light on, no staff answered the call light, so she got up out of bed. After getting up, Resident 221 stated that she could not see a path to get to the bathroom and urinated on herself. Resident 221 stated she was humiliated, but knew she needed to get back to bed. In the time that passed, no one came to answer her call light. Resident 221 stated on attempt to get back to bed she fell in her own urine, but no one came to help get her back to bed. Resident 221 stated she got back to bed without the help of staff. When a staff member did come into the room, Resident 221 stated she told them about the fall, and having urinated on the floor. Resident 221 stated the staff member made a comment to her that housekeeping did not arrive until 6 a.m. Resident 221 asked for a grabber (picker-upper) to avoid bending, ear plugs and a radio to try to drown out the noise, none of the requests were honored. Resident 221 stated she had a prescription for a marijuana pin from her surgeon. Resident 221 stated the facility staff took the Marijuana pin from among her belongings while she was out of the room. Resident 221 stated the head nurse came to her and stated that facility had confiscated the marijuana pin, called Family 2 to pick up the marijuana pin, and planned to release it to him. Resident 221 stated despite her insistence that she had a prescription for the marijuana pin, she was told it was illegal to have it in the facility. Resident 221 stated they went into my room and took my stuff .Isn't that theft. During an interview on 3/7/18 at 8:20 a.m., DON (Director of Nursing) stated No one is allowed to have marijuana, not in my building. One of the aides picked it up from Resident 221's bedside table and brought it to me. DON stated that when she was informed it was a Marijuana pin she went directly to Resident 221, who was receiving physical therapy at the time, and told her the facility was confiscating the pin. DON stated she informed Resident 221 that she had telephoned Family 2 to come to pick up the Marijuana pin, and would release the pin to him. When questioned about her method of removing the Marijuana pin while the resident was out of the room, DON stated the former DON would have called the police in this matter. DON stated she did not remember the name of the staff member who brought the Marijuana pin to her. During a concurrent interview and observation on 3/7/18 at 8:34 a.m., of activities supplies was made. A radio was observed and Activities Director stated the radio was one of two that belonged to the facility. When asked about ear plugs. Activities Director stated the previous activity director must have ordered them because she recently threw out a box of them. Activities Director stated she did not remember any resident asking for ear plugs. During an interview on 3/7/18 at 8:42 a.m., Rehabilitation Director stated the facility kept a supply of grabbers/picker-uppers, to assist any resident who needs one. Rehabilitation Director stated that in the event the supply is depleted and a resident asked for a grabber, the rehabilitation staff taught strategies to safely obtain items until the equipment was replaced. Replacement took 2 to 3 days. During a review of the clinical record for Resident 221, the Physicians Progress Note dated, 12/9/17, indicated: .Multiple intolerances of medications/opiates trial suboxone (a medication for pain) 1-2 mg (milligram). lots of questions/ long story of previous history/current condition. Complaint fell attempting to get to BR(bathroom)-3 days ago. During a review of the clinical record for Resident 221, the Interdisciplinary Team Conference Record dated, 12/11/17, indicated: .On Friday 12/8/17 resident was in possession on her over head table while out of room in Therapy of a cannabis pen which was brought to DON for safety .Resident stated, my doctor said I could use it. Pen was secured .Son was irate because pen was taken from her .Resident has hip precautions and is claiming she has fallen and got herself up without witnesses present .Resident requested pharmacist to discuss medications .then claimed he wanted to see her vagina .Therapy gave resident a shower Wednesday, Friday, CNA (Certified Nursing Assistant) reports 2 additional showers on Sunday and is demanding another shower today (Monday) . During a review of the clinical record for Resident 221, the MDS (Minimum Data Set) dated, 12/08/17, indicated: Brief Interview for Mental Status score of 15, which indicates alert and oriented. During a review of the clinical record for Resident 221, the History and Physical from local hospital dated, 11/21/17, indicated: Medications: 1. Ibuprofen as needed. 2. Medical Marijuana. 3. Meloxicam 4. Voltaren. During a review of the clinical record for Resident 221, the Resident [NAME] of Rights dated, 5/11, indicated: .7. To be encouraged and assisted throughout the period of stay to voice grievances and recommend changes in policies and services to facility staff and/or outside representatives of the patient's choice, free from restraint, interference, coercion, discrimination or reprisal .12. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs .16. To retain and use personal clothing and possessions as space permits, unless to do so would infringe upon the health, safety or rights of the patient or other patients. During an interview on 3/7/18 at 8:20 a.m., DON was asked for a policy and procedure for Medical Marijuana and she stated the facility did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident's safety when nursing staff did not evaluate, develop, and implement adequate interventions and did not implement adequate supervision and assistance for 3 Unsampled Residents (Resident 45 48, and 63), who had poor safety awareness and a history of falls, to prevent multiple falls. This failure contributed to: 1. Resident 45 fell 2 times in a 5-month period from 6/27/17 to 11/24/17. 2. Resident 63 fell 3 times in a 4-month period from 9/18/17 to 1/25/18. The fall on 11/10/17 resulted in right forehead swelling and the fall on 1/25/18 resulted in a left hip fracture, which required admission to an acute care facility for treatment. 3. Resident 48 fell while trying to get up on his own on 3/7/18. Resident 48's bed alarm battery was dead at the time of fall. Findings: 1. A review of Resident 45's admission record, dated 2/28/11, and readmit, dated 2/24/16, Resident 45's physician Progress Note, dated 6/14/17 and 1/18/18, and History and Physical, dated 7/19/17, revealed Resident 24 had diagnoses including dementia (memory loss that gets worse over time), difficulty in walking, muscle weakness [worse in upper extremities due to cerebral vascular accident (Stroke caused by a disruption of the blood supply to a part of the brain)], lack of coordination, history of falling, dysphagia (difficulty with swallowing), and aphagia (inability or refusal to swallow). Resident 45's quarterly MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 5/10/17, indicated Resident 45's BIM (Brief Interview of Mental Status) of 7 (a score of 7 or less represented severely cognitively impaired), walking did not occur, and one person physical assist with moving from a seated to standing position, moving on and off the toilet, and transfer between bed and chair or wheelchair. Resident 45's Fall Risk Assessment, dated 5/9/17, indicated Resident 45 had a score of 17 (a score of ten or greater represented high fall risk). A review of Resident 45's Resident Care Plan for Fall Risk Prevention and Management, dated 2/9/17, indicated fall risk interventions included orient resident to the environment each time changes are made, call light within reach and remind resident to use call light, bed in a low position, and encourage use of wheelchair and transfer pole [A transfer device (floor-to-ceiling grab bar) used to promote independent standing and transferring for residents with weakened strength]. Resident 45's Fall Risk care plan did not specify: 1. how the facility would provide reminders so Resident 45 would remember to ask for assistance with transferring, 2. how often the facility would do visual checks/supervision, and 3. the need for assistance when transferring to the wheelchair or when using the transfer pole. A review of Resident 45's Physician Recap Orders, dated 3/18, indicated Resident 45 was to have nursing assist with safety functional mobility with standing balance at transfer pole. Order originated on 3/28/16. First Fall A review of Resident 45's SBAR (Subject, Situation, Assessment, Recommendation) Communication Form, dated 6/27/17, Licensed Nurses Notes, dated 6/28/17 and Interdisciplinary Team (a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) Conference Record, dated 6/28/17, indicated Resident 45 had a unwitnessed fall on the AM shift on 6/27/17. Resident 45 was found on the floor next to his bed. Resident 45 told staff he had tried to transfer from the wheelchair to the bed on his own and ended up falling on his bottom because his wheelchair had moved from under him. Fall 2 A review of Resident 45's SBAR Communication Form, dated 11/24/17, Post Fall Assessment, dated 11/24/17, and Interdisciplinary Team (IDT) Conference Record, dated 11/27/17, indicated Resident 48 had an unwitnessed fall on 11/24/17 in the dining room. Resident 48 told staff he slipped out of his wheelchair while attempting to propel himself back to his room without assistance. Resident 45 had slight redness to back of head. A review of Resident 45's Resident Care Alert, dated 6/28/17 and Certified Nursing Assist (CNA) Instructions for Bed Mobility and Transfers, dated 6/21/17, indicated: 1. Resident 45 was not to be left in a room while in his wheelchair unattended, 2. Resident 45 was to be assisted from his wheelchair to his bed to avoid self-transfers, and 3. Resident 45 needed two person assist using a gait belt (An assistive devices used to help lift, position and secure individuals during walking and transfers) when transferring from the bed to the wheelchair while using a transfer pole. Resident 45's Fall Risk Assessment, dated 10/21/17, indicated Resident 45 had a score of 12 (a score of ten or greater represented high fall risk. Resident 45's quarterly MDS, dated [DATE], indicated Resident 45's BIM of 5 (severely cognitively impaired), needed one person physical assist with transfer between bed and wheel chair, and had one fall with no injury. A review of Resident 45's Resident Care Plan for Fall Risk Prevention and Management, revised 10/21/17, did not indicated any new fall risk interventions. The care plan for falls did not specify how the facility would provide supervision to prevent Resident 45 from falling, who was severely cognitively impaired, and continued to be left unattended in a wheelchair. A review of Physical Therapy Progress Report, dated 11/6/17, indicated Resident 45 had decreased balance, body awareness deficits, gross motor coordination deficits (skills which are important for major body movement such as walking, maintaining balance, coordination, and jumping), and strength impairments. During an interview on 3/1/18 at 10:50 a.m., when Unlicensed Staff N was asked about Resident 45's mobility, Unlicensed Staff N stated Resident 45 should not get up on his own. Unlicensed Staff N stated Resident 45 did have a transfer pole, but Resident 45 should not have a transfer pole because he tries to self-transfer himself and he is not able to. Unlicensed Staff N stated Resident 45 needed two people to assist with his shower. Unlicensed Staff N stated Resident 45 could walk approximately 20 feet (from the nurse's station (North Lytle) to his room, but needed to be assisted. When Unlicensed Staff N was asked how she was made aware of Resident 45's need for assistance with transferring, Unlicensed Staff N stated she was made aware by the CNA tending to Resident 45 from the previous shift. Unlicensed Staff N stated Resident 45 had a physical therapy evaluation and had transfer instructions located on the wall near his bed. 2. A review of Resident 63's admission record, dated 9/13/17 and readmit date d, 1/31/18, Physician Orders, dated 12/17, and an Emergency Department Report, dated 9/13/17, indicated Resident 63's diagnosis included Alzheimer's disease (most common cause of dementia, a group of brain disorders that results in the loss of intellectual and social skills. These changes are severe enough to interfere with day-to-day life), muscle weakness, difficulty in walking, muscle weakness, and dysphagia. A review of Resident 63's admission MDS, dated [DATE], indicated Resident 63 had a BIM score of 1 (severely cognitively impaired), needed two plus person physical assist with transfer, did not walk, one person physical assist while in wheelchair, and Resident 63 had an unsteady balance during transitions from seated to stand position and transfer between bed and chair or wheelchair. Resident 63's Fall Risk Assessment, dated 9/19/17, indicated Resident 62 had a score of 15 (a score of ten or greater represented high fall risk). A review of Resident 63's Resident Care Plan for Fall Risk Prevention and Management, dated 9/15/17, indicated Resident 63 had limited mobility, poor balance, cognitive deficit (resulting in confusion, poor motor coordination, and loss of short-term or long-term memory), unsteady gait, forgets to call/wait for assistance, impulsive behavior, history of falls, muscle weakness, and difficulty in walking. Fall risk interventions included orient resident to environment each time changes occur, call light within reach, remind resident to use call light, and bed in low position. A review of Resident 63's medical records indicated she had fallen on 9/18/17, 11/10/17, and 1/25/18. During an interview on 3/07/18 at 10:50 a.m., Medical Records was asked to locate SBAR/IDT notes regarding falls due Resident 63's chart was thinned out and none were in her chart. No SBAR was provided for the fall, which occurred on 9/18/17. During an interview on 3/07/18 at 11:05 a.m., surveyor asked Consultant to see Resident 63's investigation reports for falls, which occurred on 9/18/17, 11/10/17, and 1/25/18; none were provided. No SBAR was provided for the fall, which occurred on 9/18/17 and no nurse's notes were provided detailing post fall neuro checks (level of consciousness, movement, sensation .). Fall 1 A review of Resident 63's IDT Conference Record, dated 9/19/18, indicated CNA was giving care to Resident 63's roommate on 9/18/17, when CNA heard Resident 63 call out. Resident 63 was found on the left side of her bed on the floor. The fall caused a small laceration (cut, tear) on Resident 63's left shoulder. The IDT note indicated Resident 63's bed was to be moved up against the wall for safety, and when Resident 63 was in bed a floor mat (helps reduce injuries caused by resident falling out of bed) would be placed on the floor next to the bed. A review of Resident 63's Resident Care Plan Short Term, dated 9/19/17, indicated to move bed against wall and have drop mat on floor when resident is in bed. A review of Resident 63's Resident Care Plan for Fall Risk Prevention and Management, dated 9/15/18, was not updated and did not indicated any new fall risk interventions. Fall 2 A review of Resident 63's SBAR (Subject, Situation, Assessment, Recommendation) Communication Form, dated 11/10/17, Post Fall Assessment, dated 11/10/17, and IDT Conference Record, undated, indicated Resident 63 had an unwitnessed fall on 11/10/17 at about 2:30 p.m. Resident 63 was found on her buttock (behind) next to her bed. Resident 63 sustained right side of forehead swelling from the fall. Resident 63 was unable to recall what she was doing due to her dementia. Resident 63 was not able to be educated about waiting for assistance and using call light due to severe dementia. A review of Resident 63's Resident Care Plan Short Term, dated 11/13//17, indicated to apply first aid to forehead and for Resident 63 to continue to work with physical therapy for safety. A review of Resident 63's Resident Care Plan for Fall Risk Prevention and Management, dated 9/15/18, was not updated and did not indicated any new fall risk interventions. The care plan for falls did not specify how the facility would provide supervision and how often staff should make room rounds for Resident 63, who was severely cognitively impaired. Fall 3 A review of Resident 63's SBAR (Subject, Situation, Assessment, Recommendation) Communication Form, dated 1/25/18, Post Fall Assessment, dated 1/25/18, and IDT Conference Record, undated, indicated Resident 63 had an unwitnessed fall on 1/25/18 at about 4 p.m. Resident 63 was found lying on the floor on her left side wrapped in her blanket. Resident 63 screamed when nurse tried to assess left leg. Resident 63 was sent to an acute care emergency department for an evaluation of the left hip. A review of Resident 63's Surgery and Procedure Report, dated 1/27/18 and Discharge Summary Report, dated 1/31/18, indicated Resident 63 had sustained a fracture of the left hip and had surgery. Resident 63 had to have 4 units of blood post injury due to Resident 63's hemoglobin (The main functional constituent of the red blood cell, serving as the oxygen-carrying protein); was 6.9 [Normal level was 12-16 g/dL (grams/deciliter)] During an interview on 3/6/18 at 5:15 p.m., surveyor had to ask for SBAR, care plan for falls prior to 1/25/18 fall, Fall Risk Evaluation prior to fall and Post Fall Assessment because they were not in Resident 63's chart. Investigation Report was not provided. Resident 63's chart was thinned. When DON was asked how can contracted/traveling nurses get to know the residents if the residents' charts are thinned, DON stated Resident 63 was considered a new admit because she was transferred to an acute care facility for more than one day. DON stated a resident's chart only had a 3 month window of information. DON stated Resident 63's fall with major injury was not an unusual occurrence for Resident 63, due to her diagnosis of Alzheimer's. During an interview on 3/7/18 at 8:45 a.m., DON (Director of Nursing) stated Resident 63 walked out near her bedroom door and DON heard the fall and went right into Resident 63's room. DON stated Resident 63 was transferred to an acute care facility for further evaluation. DON stated Resident 63 forgets she cannot walk on her own and needed assistance even with transferring from the bed to the wheelchair. DON stated the fall took place on 1/25/18 at around 3 p.m. (change of shift). DON stated Resident 63 had a drop mat and was spot checked frequently (sometimes 20, 40, 60 minute checks). When the DON was asked how a CNA could be pulled to do almost a 1:1 supervision on Resident 63 when the facility did not have enough CNAs to supervise residents who were eating in their rooms and needed to be supervised (per a concurrent observation and interview on 2/28/18 at 2:10 p.m., there was no staff supervising Resident 5 while she was eating her meal. Licensed Staff H stated the certified nursing assistant (CNA) would go between Resident 5 and Resident 38, but there was not enough staff to assist residents who were eating in their room and in the assisted dining room at the same time.); DON could not answer question. DON stated the close monitoring for Resident 63 happened at times. DON stated Resident 63 did not have a bed alarm. DON stated Resident 63 could communicate, but rarely made since. 3. During an interview on 3/7/18 at 8:30 a.m., Licensed Staff B (who worked the night shift on 3/6/18) stated Resident 48 had tried to get up on his own and was found lying on floor by the CNA making rounds near the change of shift (AM of 3/7/17). Licensed Staff B stated the bed alarm did not go off because the battery was dead. Licensed Staff B stated Resident 48 had no injury. When Licensed Staff B was asked if there was enough nursing staff scheduled for 3/6/18 night shift, she stated a CNA had called in sick on the night shift, so they were short one CNA. Licensed Staff B stated she was assigned to 38 residents; there were 2 nurses and 3 CNAs scheduled last night for 68 residents. A review of Resident 48's Quarterly MDS, dated [DATE], indicated Resident 48 had a BIM score of 3 (severely cognitively impaired), needed one person physical assist with transfer between bed, chair, and wheel chair, one person physical assist with walking, used a walker, and had one fall with a minor injury. During a concurrent record review and interview on 3/7/18, at 9:05 a.m., Licensed Staff H stated Resident 48 had a bed alarm (a device attached to the bed that triggers an alarm when the resident attempts to get up from the bed). Licensed Staff H stated nursing staff should check the battery at least daily and check bed alarm functioning at least every shift. Licensed Staff H stated this should be addressed in the care plan and in the physician order, but they lacked documentation. Licensed Staff H reviewed the MAR (medication administration record) and stated no documentation for the bed alarm. She stated it could be documented in the TAR (treatment administration record). Licensed Staff H further stated they should have care instructions in Resident 48's room for CNAs (certified nursing assistant) to check the bed alarm. Licensed Staff H reviewed all the care instructions in Resident 48's room and stated no instruction for the bed alarm. During a concurrent record review and interview on 3/7/18, at 9:09 a.m., Licensed Staff J reviewed the TAR and stated no order or documentation for the bed alarm. Resident 48's physician order list, dated March 2018, did not include an order for the bed alarm. Resident 48's care plan for fall risk prevention and management, dated on 1/10/18, indicated Resident 48 was at risk for fall due to multiple problems including history of falls, poor balance, lack of awareness, hearing deficit, vision deficit, and cognitive deficit. One of the approaches was to encourage Resident 48 to use of assistive device, bed alarm. The care plan was revised to include Replace Battery as needed on 3/7/18 (Resident 48 fell on 3/7/18 at 1:15 a.m.). The care plan did not specify when and how staff would check the battery or bed alarm functioning. The care plan did not specify providing supervision to Resident 48 to prevent falls. Review of the facility policy/procedure titled, Fall Management Program, revised 11/7/16, indicated: 1. The Licensed Nurse and/or IDT will develop a Plan of Care according to the identified risk factors and root cause per Care Area Assessment guidelines, 2. Following each Fall, the Licensed Nurse will perform a Post-Fall Assessment and update, initiate or revise a Plan of Care, 3. Once the post fall huddle is complete the Licensed Nurse will update the care plan with immediate recommendations, 4. The IDT will summarize conclusions after their review of the fall and circumstances surrounding the fall . The plan of care will also be reviewed and the care plan will be revised as necessary in an effort to prevent further falls with a major injury, and 5. A resident who sustains multiple falls as defined as more than one fall in a day, a week, or month, will be considered a high risk to fall and as a result may sustain a major injury. These residents may be identified by a special logo or designation to alert staff to their high risk activity, may require more frequent observation of activities and whereabouts .

Based on observation, interview, and record review, the facility failed to provide pain management to one of seventeen residents (Resident 16) when Resident 16 complaint of pain and she did not received care based on comprehensive person-centered care plan to meet Resident 16's goals and preferences. This failure resulted to Resident 16 experiencing pain and felt like screaming. Findings: During the initial interview on 2/26/18, at 4:34 p.m. Resident 16 stated her morphine pain medicine was cut in half and it would take a while for it to build up in her system. During the record review on 2/26/18, at 4:39 p.m., the medical records indicated Resident 16 had diagnosis of Chronic Pain Syndrome ( pain associated with significant psychosocial dysfunction. A pain lasts longer than six months. It is the combination of chronic pain and the secondary complications that are making the original pain worse), stiffness of unspecified shoulder, muscle weakness, and Chronic Obstructive Pulmonary Disease (COPD- is a progressive disease that makes it hard to breath that gets worse over time). The facility put Resident 16 on Hospice service (services provided to a terminally ill individual) on 12/4/17. The Hospice Clinical notes, dated 12/4/17, indicated, .I [Hospice Service Physician] expect she will survive fewer than 6 months. The most recent Minimum Data Set (resident assessment tool) dated 12/11/17, indicated Resident 16 had a moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.), in which Resident 16 was able to recall 2 out of 3 words without cues. During an observation and interview on 3/01/18, at 10:43 a.m. while sitting on the wheelchair, Resident 16 stated, Pain is bad. I don't know who to ask for it and talk about it. When asked how she calls for assistance, Resident 16 activated her call light. Resident 16 stated, Sometimes it takes one hour for somebody to come in and another hour to get (help with whatever she needs). During an observation on 3/01/18, at 10:46 a.m., Licensed Staff J entered Resident 16's room and answered the call light. Licensed Staff J asked Resident 16 what she needed; Resident 16 said she was in pain. Licensed Staff J asked Resident 16 where the pain was; Resident 16 stated, Everywhere, it's been quite a while, it's been increasing, and then Resident 16 pointed to her mid-lower abdomen. Resident 16 stated, It's been there two months, it hurts when I turn over. Resident 16 stated the abdominal pain was at 10 level (10/10- 10 being the highest pain) when Licensed Staff J asked. Resident 16 stated, Nothing helps, you have to find out what it is. Licensed Staff J asked Resident 16 where her other pain was. Resident 16 stated, Osteoporosis pain, 8 (pain level). Licensed Staff J told Resident 16 he would tell Resident 16's nurse. During an observation on 3/01/18, at 10:54 a.m., Licensed Staff J returned and told Resident 16 the nurse was coming to address Resident 16's pain complaint. During an observation and observation on 3/03/01/18 at 1:48 p.m., Resident 16 was sitting on her wheelchair. When asked about her pain, Resident 16 stated, I have to wait for 4 hours, I didn't know when the last time I got it or when can I get it (pain medicine) During an interview on 3/01/18 at, 1:55 p.m., when asked about Resident 16 experiencing pain, Unlicensed Staff N stated Resident 16 did have some pain in her abdomen this morning when she was providing care. When asked if she reported the pain, Unlicensed Staff N stated she did not report the pain and, I just assumed the nurse already knew. When asked to whom she should report the pain, Unlicensed Staff N stated she would report resident's pain to a charge nurse. During an interview on 3/01/18, at 2:09 p.m., Resident 16 stated she received pain med, but the pain is getting worse, and she asked the nurse to call hospice. During an interview on 3/01/18, at 2:21 p.m., Licensed Staff E, stated Resident 16 was on hospice. Licensed Staff E stated she gave morphine 1 ml, 20 milligram, as needed every 4 hours, for Resident 16's abdominal 8/10 pain level at 2:05 p.m. When asked how often she assessed Resident 16's pain, Licensed Staff E stated assessing Resident 16's pain after giving pain medicine. Licensed Staff E stated Resident 16 started complaining of abdominal pain around 11 a.m. but Resident 16 was not due to receive pain medicine. Licensed Staff E stated she assessed Resident 16's abdomen by listening to Resident 16's bowel sounds. During a review of the clinical record for Resident 16, the Medication Administration Record for 3/18 indicated, Resident 16 received Morphine 20mg on 3/1/18 at 9:30 a.m., and the nurse document the result of Morphine was helpful at 10 a.m. The MAR indicated Resident 16 received Morphine 20mg on 3/1/18 at 2:05 p.m. Licensed Staff E stated Resident 16 had a prescribed Tylenol (pain medicine) for mild breakthrough pain, and the staff were to call hospice if Resident 16's pain medicine prescribed for severe could not control the pain. When asked if she called hospice for Resident 16, Licensed Staff E stated she would call hospice staff before the shift ends. During an interview on 3/05/18, at 4:03 p.m., Hospice Staff O stated Resident 16 had a lot of issues and over doing pain med. Hospice Staff O stated, We've had her (Resident 16) for years, on and off. Hospice Staff O stated the hospice physician changed Resident 16's Morphine 20mg from every two hours to every four hours, as needed, because Resident 16 would be unresponsive if she was getting a lot. During an interview on 3/05/18, at 4:36 p.m., Hospice Staff P stated, on 2/15/18, the Hospice Service started Resident 16 on low dose Methadone (synthetic, narcotic analgesic (pain reliever) and used for other medical purposes such as pain relief.) and changed the morphine from every two hours to every four hours. Hospice Staff P stated the facility requested to change the morphine because Resident 16 was falling from oversedation (reduction of anxiety, stress, irritability, or excitement by administration of a sedative agent or drug.). Hospice Staff P stated hospice nurse visits Resident 16 once a week, unless Resident 16 needed more hospice services. Hospice Staff P stated the facility staff should contact Hospice Service if Resident 16 reported increasing severity of pain. During an interview on 3/06/18, at 8:26 a.m., Resident 16 stated her pain goal was to get pain level down to 5, where she did not feel like screaming all the time. When asked how often staff were addressing her pain, Resident 16 stated, Nothing really gets done about it. 1-2 nurses seems to understand and care and the rest ignore you. You can't do anything just lay in there. I haven't been ok for a long time, I tried to act like I'm ok. I tried to smile. When asked how often she have to ask for pain medicine, Resident 16 stated, I don't think if I had it. I feel stupid if I asked and then they told you, 'you had one'. (It) doesn't really help if I had one or not. When asked if the pain medicine helps, Resident 16 stated, It doesn't seem to, I can't tell if had it or not, so obviously it does not help me much During an interview on 3/06/18, at 8:35 a.m., Licensed Staff E stated she have not given Resident 16's any medications yet. Licensed Staff E stated Resident 16 received morphine on 3/5/18 at 8:45 p.m. During an interview and concurrent record review on 3/06/18, at 4:53 p.m., when asked about a tool used to assess residents with pain, the Director of Nursing (DON) stated they used pain management that includes giving pain medicine like Norco (acetaminophen and hydrocodone), Morphine, Methadone, using distraction, hot pack, pain assessment using 1-10 pain scale if residents are alert and oriented, and checking for grimaces for non-verbal resident. The DON stated the Certified Nursing Assistant (CNA) would bring the information to the nurse, and the nurse would assess and do what they can to help. Regarding Resident 16's pain management, when asked how and when do staff try to identify circumstances in which pain can be anticipated, the DON stated Resident 16 started with certain amount of morphine and methadone and that they (Hospice Service) increased methadone to work long term better. The DON stated, She's (Resident 16) pretty good at telling us her pain. The DON stated the Hospice Service increased her long term (long-acting medication) so she doesn't get snowed (oversedated). The DON stated the facility put Resident 16 on Hospice Service because she likes getting extra attention as told by Resident 16 to the DON. When asked how often Resident 16's pain assessment was, the DON stated the staff should assess Resident 16's pain at the beginning of every shift, before medication, and report from other shift whether she had pain medication before. The DON stated the staff would call hospice service if Resident 16's pain appeared to be out of control, and the hospice staff could do another reassessment. When asked how staff communicates with the physician about the resident's pain status, current measures to manage pain, and the possible need to modify the current pain management interventions, the DON stated, Hospice is driving her care. When asked how the facility developed the interventions, the DON stated, the facility tried to convince her to get out of her room, to join activity, to put hot pack on shoulders, to rest, and for Resident 16 to lay on her back when sitting in wheelchair for too long. The DON stated, the facility performed conference care between Hospice Service and DON and worked conjunctively. When asked if any of Resident 16's interventions been effective, the DON stated, I think so, I don't think if she would agree with me. The DON stated Resident 16 had high tolerance of pain, that's why it's a work on progress. The DON stated, Her (Resident 16) favorite is every 1 hour pain med, even if you tell her, she forgets. The DON stated the facility have not tried communication board or visual reminders informing Resident 16 about her pain medicine. The DON verified Resident 16 Care Plan for Pain had no measureable goals, no measureable pain assessment frequency, and not Resident 16-centered. When the DON was informed Resident 16 waited for hours (from the time Resident 16 complaint of pain at 10: 46 a.m until she received pain medicine at 2: 05 p.m.) in pain until Morphine was due, the DON stated the staff should have call the Hospice Service if there was no pain medicine available. During a review of the clinical record for Resident 16, the Nurses Note, dated 12/18-2/15/18, had no documentation of Resident 16 being oversedated. During a review of the clinical record for Resident 16, the Palliative Care Form signed and dated by a physician on 11/14/16, indicated, The resident will require the frequent use of narcotic/anti-anxiety/hypnotic medications (treatment for pain, anxiety and sleeping problems) . The facility/agency will plan and implement measures to maintain the appropriate levels of medication for the resident to ensure comfort. During a review of the clinical record for Resident 16, the Resident Care Plan: Pain dated 12/17, indicated planned goals of Resident will verbalize/show decreased signs and symptoms of pain, and resident will require less pain medication to alleviate pain. The facility did not mark a pre-written planned goals indicating, Resident will achieve self-reported pain goal of (1-10):___; there was no written pain goal established. The planned approach indicated, Evaluate need for routine pain medication rather than PRN [as needed medication]. During a review of the clinical record for Resident 16, the Resident Care Plan: Palliative (specialized medical and nursing care that focuses on providing relief from the symptoms of pain, physical stress, and mental stress of a terminal diagnosis for people with life-limiting illnesses) dated 12/17, indicated a problem/need of use of narcotic/anti-anxiety/hypnotic medications (treatment for pain, anxiety and sleeping problems) with planned goal of Resident will be comfortable and pain free through terminal illness. The facility policy and procedure titled Pain Management dated 11/16, indicated, for Pain Assessment: The Interdisciplinary Team will develop a resident centered care plan for pain management, including non-pharmacological interventions. Goals for pain management and the acceptable level of pain relief will be determined in conjunction with the resident when possible. For Pain Management: Nurses will complete the Pain Flow Sheet for residents receiving PRN [as needed] pain medication to evaluate the effectiveness of the medication regimen .Nursing staff will implement timely interventions to reduce an increase in severity of pain .Nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain . The facility policy and procedure titled Hospice Care of Residents dated 1/1/12, indicated, The resident's right to comprehensive pain and symptom management at the end of life, including but not limited to: Adequate pain medication. During a review of the Hospice Care Plan, provided by the facility on 3/13/18, the Care Plan for pain indicated to meet Resident 16's desired pain goal of 4/10. The facility policy and procedure titled Comprehensive Person-Centered Care Planning dated 11/17, indicated, The baseline care plan must reflect the resident's stated goals and objectives, and include interventions that address his or her needs.