**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 48's admission Record indicated the facility admitted Resident 48 on 1/26/2022, with diagnoses including repeated falls and pneumonia (an infection that inflames the air sacs in one or both lungs). A review of Resident 48's MDS dated [DATE], indicated Resident 48 had moderately impaired cognition and the resident required limited assistance with one-person physical assistance for activities of daily living (ADLs, such as transferring, walk in room and corridor, dressing, toilet use, and personal hygiene). A review of Resident 48's Physician's History and Physical (H&P) dated 1/27/2023, indicated the resident had fluctuating (changing) capacity to understand and make decisions. A review of Resident 48's Physician's Orders dated 6/7/2023, indicated to place a wander guard alarm on the resident at all times during every shift. A review of Resident 48's Care Plan dated 6/7/2023, indicated Resident 1 had an episode of wandering and he was trying to leave the facility through the back entrance. The care plan goal indicated Resident 48 would not leave the facility without the staff being alerted. The interventions indicated the following: place a wand guard alarm on resident at all times and check the wander guard alarm to see if it was working at all times. A review of Resident 48's admission Elopement (left the facility without notice or permission, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave) Risk assessment dated [DATE], indicated the resident was alert and oriented, dependent for mobility and had zero attempts to leave the facility. A review of Resident 48's Quarterly Wandering Risk assessment dated [DATE], did not indicate any entry responsive to the assessment questions. The assessment form status was in progress. The assessment did not indicate any wandering risk score or category. A review of Resident 48's SBAR Communication Form dated 6/7/2023, indicated the resident had an episode of wandering and he was trying to walk away from the facility. The form further indicated Resident 48 was seen walking down the ramp at the back of the facility towards the parking area. A review of Resident 48's Quarterly Wandering Risk assessment dated [DATE], indicated the resident was disoriented. However, the rest of the assessment categories were not completed. During an observation on 11/13/2022 at 11:40 AM, Resident 48 was observed sitting on his wheelchair in the activity room. LVN 1 was present in the activity room. LVN 1 checked for Resident 48's wander guard alarm on his legs and could not find an alarm. LVN 1 then informed Registered Nurse Supervisor 1 (RN 1) that Resident 48 did not have a wander guard alarm on. During a concurrent interview and record review, on 11/13/2023 at 11:50 AM, with RN 1, Resident 48's Wander Guard Log and Wandering Assessments were reviewed. RN 1 stated she checked Resident 48's wander guard alarm today and she documented in the log that he was wearing it. However, RN 1 and surveyor went inside Resident 48's room and found the resident's wander guard alarm inside his bedside drawer. RN 1 stated, I did not physically check the placement of Resident 48's alarm on his leg today and I just documented in the log that I did. RN 1 stated false information was provided. RN 1 stated Resident 48's Wandering Assessments dated 5/1/2023, and 11/2/2023, were not completed. RN 1 stated, It was required to complete the assessment forms thoroughly because that was how we determine whether or not a resident was a high risk for elopement. RN 1 stated the potential outcome was lack of proper monitoring which could lead to a resident's elopement. During an interview on 11/14/2023 at 9:04 AM, with MDS Coordinator (MDSC), the MDSC stated elopement risk assessment was completed upon residents' admission to the facility, if there was a change in condition, and also quarterly. The MDSC stated, I normally open the assessments when they are due. I either complete the assessment, or I ask one of the licensed nurses to complete the assessment. The MDSC confirmed that Resident 48's elopement risk assessments dated 5/1/2023, and 11/2/2023, were incomplete. The MDSC stated, These ones were missed. The MDSC stated Resident 48 attempted to elope on 6/7/2023 and If the resident's quarterly assessment on 5/1/2023, was completed, we could have potentially prevented the resident from eloping by placing a wander guard alarm on him. The MDSC stated the potential outcome of an incomplete elopement risk assessment form was the risk of possible elopement. During an interview on 11/16/2023 at 12:40 PM, the Director of Nursing (DON) stated staff were required to make sure the wander guard alarm was placed on residents during every shift. The DON stated staff were required to make sure the alarm was functioning at all times. The DON stated documenting in wander guard log without physically checking the placement of the wander guard alarm on residents was a deficient practice. The potential outcome was not being able to detect whether or not a resident was wearing an alarm which could lead to possible elopement. The DON further stated the Wandering Risk Assessments forms were required to be completed thoroughly by licensed staff. The DON stated the potential outcome was an inaccurate assessment, failure to monitor residents properly, and potential risk for elopement and harm. A review of the facility's policy and procedure titled, Wandering and Elopement, revised 3/2019, indicated the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining at least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. A review of the facility's policy and procedure titled, Elopement, revised 11/14/2023, indicated licensed staff will do the elopement assessment upon admission, readmission, quarterly, and identification of significant change of condition according to Resident Assessment Instrument (RAI- a comprehensive assessment and care planning process used by the nursing homes). A review of the facility's policy and procedure titled, Safety and Supervision of Residents, revised 7/2017, indicated resident safety and supervision and assistance to prevent accidents were facility - wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. Monitoring the effectiveness of the interventions shall include the following: ensuring the interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying, or replacing the interventions as needed. Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (Resident 3, Resident 31 and Resident 48), received services to prevent accidents. a.For Resident 3, who was diagnosed with left above the knee amputation (AKA- surgical removal of a person's leg above the knee) and end stage renal disease (ESRD - the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life), the facility failed to ensure Resident 3 received two or more-person physical assistance when transferring Resident 3 from wheelchair to car per the comprehensive assessment and the facility failed to develop care plan interventions regarding Resident 3's need for two-person transfer, Hoyer lift, or sliding board for transfer. As a result of this deficient practice Resident 3 was solely transferred from wheelchair to car by Certified Nursing Assistant 1 (CNA). Resident 3 sustained an injury to her right leg, that caused her severe pain and required multiple x-rays to rule out a fracture. b.For Resident 31, who had a history of repeated falls, the facility failed to implement fall prevention interventions as indicated in the risk for falls care plan. As a result, Resident 31 fell from a wheelchair and developed a head injury, face abrasion (type of open wound that's caused by the skin rubbing against a rough surface), and a face contusion (bruise, when small blood vessels break open and leak blood into the nearby area). c.For Resident 48, the facility failed to ensure the resident was wearing his wander guard (a device worn by residents to help monitor their whereabouts using an alarm system). As a result, Resident 48 had the potential to leave the facility without supervision and come to harm. Findings: a. A review of the admission Record indicated the facility initially admitted Resident 3 on 6/6/2023 and readmitted the resident on 6/20/2023 with diagnoses including AKA and ESRD and hypotension (low blood pressure). A review of the care plan initiated 6/21/2023 indicated Resident 3 was at risk for activities of daily living (ADLs -essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) self-care performance related to her diagnoses of ESRD and left aka. The goal was that the resident will maintain current level of function through the review date. The care plan addressed the interventions for the resident including bathing/showering (avoid scrubbing and pat dry sensitive skin), bed mobility (the resident is able to turn and reposition herself), eating (provide finger foods when the resident has difficulty using utensils). A review of the care plan indicated the ADL of transferring was not addressed and interventions were not developed. The care plan also did not indicate Resident 3 required two or more person assist with transfer. A review of Resident 3's skin breakdown care plan, initiated 6/21/2023, indicated the resident was at risk for pressure injury development due to limited mobility and need for dialysis. The goal was for the resident to have intact skin, free of redness, blisters or discoloration. The care plan indicated the interventions / tasks included the resident prefers to be repositioned with two people, lifter, slider. A review of the History and Physical (H&P), dated 6/26/2023, indicated Resident 3 had a left AKA with healed stump and had fluctuation capacity to understand and make decisions. The H&P indicated Physical/Occupational Therapy would need to find her prosthesis (device designed to replace a missing part of the body or to make a part of the body work better). A review of the ADL assistance care plan, initiated 6/28/2023, indicated Resident 3 needed assistance with bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene and bathing. It indicated a goal was for the resident to maintain her present level of ADL self-performance. The interventions included to allow sufficient time for ADL task, provide verbal cues with ADL care needs and to monitor for change in self performance of ADLs. The care plan did not indicate Resident 3 required use of two or more persons or a Hoyer lift for transfer. A review of the Morse Fall Scale dated 9/25/2023, indicated Resident 3 had an impaired gait consisting of difficulty rising from chair, used chair arms to get up, grasps furniture, required an aid when ambulating and could not walk unassisted. The Morse Fall Scale indicated the resident knew her own limits and that the resident was a moderate risk for falling. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/26/2023 indicated Resident 3 had clear speech, able to make herself understood and could understand others. Resident 3 had adequate hearing and vision. The MDS indicated Resident 3 needed one-person physical assistance with bed mobility, dressing, toilet use, personal hygiene, or bathing and required two or more persons physical assistance with transfer. It also indicated the resident normally used a wheelchair for mobility and had a functional limitation in range of motion on one side of her body. A review of the Nurses Note, dated 9/28/2023 at 8:45 PM, indicated Resident 3 returned from an appointment at 4:45 PM and complained of right ankle and right lower leg pain rated an 8 out of 10 (severe pain). Resident 3 reported the pain occurred in the morning when she twisted her right lower leg upon transfer from wheelchair to car. The Nurses Note indicated Resident 3 was administered Norco (an opioid pain medication for moderate to severe pain). The resident's physician was informed, and he ordered an x-ray to rule out a fracture (broken bone) for Resident 3. A review of the Nurses Note, dated 9/29/2023 at 7:08 PM, indicated the facility was monitoring Resident 3 for lower leg and ankle pain. Resident 3 requested Norco for lower leg pain with a pain level rated at 6 out of 10 (moderate pain). A review of Resident 3's Medication Administration Record for 9/2023, indicated the facility administered Norco 5-325 milligram (mg) tablet to Resident 3: -for pain level of 8/10 on 9/28/2023 at 4:50 PM -for pain level of 6/10 on 9/28/2023 at 9:15 PM -for a pain level of 6/10 on 9/29/2023 at 5:44 AM and 2:39 PM -for a pain level of 6/10 on 9/30/2023 at 9:07 AM and; -for a pain level of 7/10 on 9/30/2023 at 5:30 PM. A review of the Order Summary Report, indicated on 9/28/2023, Resident 3 was to receive an x-ray of her right ankle due to increased pain. According to a review of the X-ray Report dated 9/28/2023, Resident 3 had a nondisplaced fracture (the bone cracks or breaks but retains its proper alignment of the distal tibia (forms the bony structure of the ankle joint). According to a review of the Second Opinion X-ray Report dated 9/28/2023, Resident 3 had mild arthritic changes of the ankle without obvious fracture of the distal tibia. A review of the pain care plan, initiated 9/28/2023, indicated Resident 3 had increased right leg pain. The goal was for the resident to verbalize adequate relief of pain to affected area. The interventions included to apply cam boot as ordered, administer pain medications as ordered and to monitor/record pain characteristics every four hours and as needed. A review of the general acute care hospital 1 (GACH 1) on call note, dated 10/1/2023, indicated Resident 3 had a twisting injury when going from wheelchair to an appointment on Thursday, x-ray was ordered but did not result until today (10/1/2023). It also indicated the x-ray shows an oblique non-displaced fracture lucency (refers to the less dense regions of structures, which appear darker on the X-ray image. To a radiologist, lucency was cause for concern when there was too much of it and if it was an atypical location) in distal tibia (shin bone). The GACH 1 note indicated the resident had pain that was controlled with Norco as needed. Resident 3 was ordered to not weight bear on her right leg and there was a request for the resident to be seen by the fracture clinic on the same day. A review of the Interdisciplinary (IDT - a group of staff from different fields) Progress Note dated 10/2/2023 indicated the IDT team met with Resident 3 and her family member (FM 1). It indicated Resident 3 stated the nurse transferred her to the car to go to her appointment that day. The nurse attempted to transfer her to the backseat of the car with a sliding board but it was too long and thus the nurse removed the sliding board and manually lifted the patient from wheelchair and transferred her to the car. Resident 3 felt that her foot got caught but did not know how it occurred. A review of the Physician's Orders dated 10/1/2023, indicated the following -Resident 3 was to not weight bear on her right leg every shift -Resident 3 was to have an orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) consult for follow-up treatment -Resident 3 was to have an x-ray of her right ankle due to increased pain A review of the Physician's Orders, dated 10/2/2023, indicated the facility was to transfer Resident 3 to GACH 1 for further evaluation of her right ankle pain (arthritic changes vs fracture). A review of the Emergency Department (ED) Provider note, dated 10/2/2023, indicated the resident came to the ED with the main complaint of right ankle pain. Resident 3 reported the other day she was being transferred into a car and had a twisting injury of her right ankle. Resident 3 reported that her pain had been constant since that time. A review of the GACH 1 radiology report dated 10/2/2023 of Resident 3's right ankle ndicated severe diffuse osteopenia, which limits evaluation. No acute fracture was identified. A review of the Physician's Orders dated 10/3/2023, indicated -Resident 3 was to only have weight bear on her right leg by heel touch only -Resident 3 was to have an orthopedic follow up on 10/3/2023 A review of the Orthopedic Office Visit note dated 10/3/2023, indicated Resident 3 had complaints of pain and swelling of her right foot and leg. The injury occurred on 9/28/2023 when Resident 3 hit her leg during transfer at the facility. It further indicated Resident 3 had not been ambulatory since her AKA. A review of the Physician's Orders dated 10/4/2023, indicated Resident 3 was to use a controlled ankle motion boot (CAM -lower extremity boot that provides support, protection and immobilization of the ankle after injury or surgery) for support when practicing weight bearing every shift for eight weeks and did not need to be in the boot while in bed or chair. A review of the October 2023 MAR indicated the physician ordered Resident 3 to receive an x-ray of her right lower leg due to persistent lower leg pain. A review of the radiology report dated 10/27/2023 of Resident 3's right ankle indicated lucency in the distal tibia, which was concerning for a nondisplaced fracture. A review of the radiology report dated 10/27/2023 of Resident 3's right leg indicated the resident had severe osteopenia, which may obscure a nondisplaced fracture. During an interview on 11/14/2023 at 12:15 PM, Resident 3 stated almost 8 weeks ago, she had an appointment and Certified Nursing Assistant 1 (CNA 1) squeezed her around my ribs and swung me into the car. She stomped on my leg, and squeezed me in the ribs trying to get me in the car without falling. Resident 3 stated, We almost did not make it to the car. Resident 3 stated the facility staff usually used a sliding board to get in the car. I thought she was going to put me in with the lift, but she said she couldn't do it because my daughter asked her, but I don't remember her answer. Resident 3 stated, I am supposed to wear a boot. Resident 3 stated the accident set back her physical therapy because she had recently been taken off of bed rest. During an interview on 11/14/2023 at 2:02 PM, CNA 1 stated she transferred Resident 3 to her family member's car for an appointment. CNA 1 stated she attempted to transfer Resident 3 with a sliding board but Resident 3 was not able to do it. So as a last resort transferred Resident 3 from wheelchair to the car by hugging her under her arms and carrying her to the car. Resident 3 could not reach the seat, so she had to lift her up a little to get her into the car. CNA 1 further stated she was not instructed on how to transfer Resident 3 and received one on one training after the incident and would have had another staff member assist her if she had known. During an interview on 11/14/2023 at 2:39 PM, Certified Occupational Therapy Assistant (COTA 1) stated, Resident 3 was receiving physical therapy (PT) and Occupational Therapy (OT) focusing on her core strengthening, static and dynamic balance and range of motion of her extremities, upper and lower. We tried to stand her up, but she is not there yet. COTA 1 further stated prior to the incident, Resident 3 had been on Hoyer lift transfer because she only has one leg, her prosthesis did not fit at that time, she had poor trunk control, and she could not stand up. PT verbally recommended to nursing staff to transfer Resident 3 with a Hoyer lift because with two-person transfer, Resident 3 could not bear any of her weight and that was not safe for the resident or staff. COTA 1 also stated, We were not able to provide physical therapy until last week per physician's order. During an interview on 11/15/2023 at 11:12 AM, Family Member 1 (FM 1) stated CNA 1 wheeled Resident 3 out to the car for her appointment. Basically, CNA 1 could not do it on her own. CNA 1 carried Resident 3 from the wheelchair and placed her in the car and in doing so Resident 3 hurt her leg. CNA 1 carried Resident 3 about three steps. After the transfer, Resident 3 complained of pain, would not exit the car to go to her appointment because of the pain and We had to reschedule the appointment. Upon returning, there were two nurses who helped her using the sliding board, which I suggested. FM 1 further stated Resident 3 requested a Hoyer lift but was told can't put the harness in the car. During an interview on 11/15/2023 at 12:15 PM, CNA 3 stated she was instructed to transfer Resident 3 with a mechanical lift upon hire on 9/21/2023. CNA 3 stated when she was first hired on 9/21/2023 she asked how to transfer Resident 3 and was told to use a mechanical lift. CNA 3 further stated, If I don't have a lift, I wouldn't transfer because per her care plan you have to use a mechanical lift. So, a mechanical lift would be the safest choice for her. During a phone interview on 11/15/2023 at 12:48 PM, Resident 3's primary doctor (PMD) stated that it was ultimately determined Resident 3 did not have a fracture and she was weight bearing as tolerated. During a concurrent interview and record review of Resident 3's medical chart on 11/15/2023 at 1:34 PM, the Minimum Data Set Coordinator (MDSC) stated on 9/28/2023, Resident 3 complained of worsening right ankle and lower leg pain after she twisted her lower leg upon transfer to her car per the nursing progress note dated 9/28/2023 at 8:25 PM. The physician ordered an x-ray of her right ankle and to rest, elevate and apply a cold pack to her right ankle. Thr MDSC also stated Resident 3 received Norco for her pain. The first x-ray result on 10/1/2023 indicated Resident 3 had a nondisplaced tibia fracture. The MDSC further stated a second physician read the x-ray, who determined there was no obvious fracture but mild arthritic changes. Resident 3's physician then ordered Resident 3 to be non-weight bearing on her right leg and to have an orthopedic consult. On 10/2/2023, the PMD ordered the facility to transfer Resident 3 to GACH 1 to evaluate her right ankle pain and determine if the resident had a fracture versus arthritic pain. The MDSC stated Resident 3 was required to be transferred via Hoyer lift for her safety. Upon review of Resident 3's care plans, the MDSC stated Resident 3's requirement for a 2- person, mechanical lift transfer was not care planned. The intervention should have been transferred in order for staff to know the most appropriate and safest way to transfer Resident 3 and to prevent Resident 3 from suffering injury, pain or discomfort. During an interview on 11/15/2023 2:21 PM, Registered Nurse Supervisor 1 (RN 1) stated prior to the incident Resident 3 was a two-person transfer prior to the incident on 9/28/2023. The restorative nurse aide assisted her to the car alone but should have gotten help to transfer the resident in order to prevent Resident 3 from having pain and for the safety of the resident. During an interview on 11/16/2023 at 11:05 AM, the Director of Nursing (DON) stated the CNA transferred Resident 3 to a car for her appointment. After the resident came back, she complained of pain due to the incident when she was transferred to the car. FM 1 reported the wheelchair was quite far from the car. CNA 1 transferred the resident by herself to the car and could not use the mechanical lift. CNA 1 also did not use the sliding board. The DON further stated Resident 3 was a two-person transfer, per the MDS. CNA 1 should have used the sliding board from the wheelchair to the car. Resident 3's safety was placed at risk by not using the sliding board. The resident's left AKA made her more at risk for injury during the transfer. A review of the facility policy titled, Safety and Supervision of Residents, revised on 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents were facility-wide priorities. The same policy indicated the Interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive device. The facility will implement interventions to reduce accident risks and hazards which will include ensuring that interventions were implemented. A review of the facility policy titled, Safe Lifting and Movement of Residents, revised 7/2017, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. It also indicated Nursing staff, in conjunction with the rehabilitation staff, shall assess individual. residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. A further review indicated staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. b. A review of Resident 31's admission Record indicated the facility originally admitted the resident on 8/2/2019 and re-admitted the resident on 7/25/2021 with diagnoses including age-related osteoporosis (a disease that weakens bones), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (loss of the ability to understand or express speech) following a cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), benign prostatic hyperplasia (enlarged prostate), and a history of falling. The admission Record indicated Resident 31's emergency contact was Family Member (FM) 3. A review of Resident 31's Care Plan initiated on 7/25/2021 and revised on 11/13/2023, indicated the resident was high risk for falls due to a diagnosis of dementia, poor safety judgement, history of multiple falls, use of antidepressant medication, and use of blood pressure medication. The care plan goals indicated Resident 31 will be free of falls through the review date; and the resident's risk for fall will be minimized through intervention through the review date. The care plan interventions indicated to monitor Resident 31 for episodes of restlessness due to the need for incontinence (lack of voluntary control over urination or defecation) care; to monitor the resident's behavior of trying to get out of bed unassisted, and to consider further interventions when the resident started exhibiting behavior again. A review of Resident 31's Morse Fall Scale (an assessment tool that predicts the likelihood a resident will fall) dated 9/14/2023, indicated the resident was at high risk for falling with a score of 75. The Morse Fall Scale indicated Resident 31 had a history of falling, had more than one diagnosis on the chart, did not use ambulatory aids due to bedrest, used wheelchair and nurse assistance, and had impaired gait (difficulty rising from chair, uses chair arms to get up, bounces to rise, keeps head down when walking, watches the ground, grasps furniture, person or aid when ambulating, cannot walk unassisted).The Morse Fall Scale further indicated Resident 31 overestimated or forgot the limits of their ability to ambulate safely. A review of the Physician's Order dated 9/14/2023, indicated Resident 31 was to have a low bed with floor mats to prevent injury secondary to the resident trying to get out of bed unassisted. A review of the MDS dated [DATE], indicated Resident 31 had severely impaired cognition (never/rarely made decisions), was totally dependent and required one-person physical assistance for transferring, locomotion (movement) on and off the unit, and personal hygiene. The MDS indicated Resident 31 required extensive assistance and two-person physical assistance for bed mobility and toilet use. The MDS indicated Resident 31 required extensive assistance and one-person physical assistance for dressing and eating. The MDS indicated Resident 31 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position and with surface-to-surface transferring. The MDS indicated Resident 31 normally used a wheelchair and was always incontinent of urine and bowel. A review of the Physician's Order dated 9/25/2023, indicated Resident 31 may have a tab alarm on the bed and wheelchair to alert staff, remind resident, and to prevent unassisted ambulation. A review of Resident 31's Order Summary Report indicated there were no orders to monitor Resident 31 for episodes of restlessness or behavior of trying to get out of bed unassisted. A review of Resident 31' Medication Administration Record (MAR) for 11/1/2023 to 11/30/2023, indicated there was no documentation for the monitoring of episodes of restlessness due to the need for incontinence care, or for the monitoring of the resident's behavior of trying to get out of bed unassisted. A review of the Situation Background Assessment and Request (SBAR) Communication Form dated 11/11/2023, indicated at 6:19 PM certified nursing assistant (CNA) heard a tab alarm, rushed to check, found Resident 31 lying on the floor by the hallway, and called for help. The SBAR indicated the Registered Nurse (RN) went to check Resident 31 and found the resident leaning on his left side with his face towards the floor. The SBAR indicated a neuro assessment was done, Resident 31 was alert and responsive, a skin assessment was done, and the resident was noted with a skin tear to the nasal bridge, lump on the forehead, and skin tear to the right hand. The SBAR indicated Resident 31 was able to move all extremities but was noted with discomfort at the left upper extremity upon movement. The SBAR further indicated Resident 31's primary clinician was notified on 11/11/2023 at 6:23 PM with recommendations to transfer Resident 31 to the General Acute Care Hospital (GACH) for evaluation. The SBAR further indicated Resident 31's FM 3 was notified on 11/11/2023 at 6:35 PM. A review of the Physician's Order dated 11/11/2023 indicated may transfer Resident 31 to GACH 1 ED for evaluation related to status post fall. A review of GACH 1 records indicated Resident 31 arrived to GACH 1's Emergency Department (ED) via ambulance on 11/11/2023 at 8:05 PM with a chief complaint of a head injury. A review of GACH 1's ED Care Timeline indicated on 11/11/2023 at 8:27 PM, Resident 31 was brought in by ambulance from the facility complaining of a fall with a hematoma (an abnormal pooling of blood in the body under the skin that results from a broken or ruptured blood vessel) on the forehead, laceration (a deep cut or tear on the skin) on the nose, and left hand and shoulder pain. A review of GACH 1 ED Provider Notes dated 11/11/2023 at 8:53 PM, indicated Resident 31 was sent to GACH 1 from the facility to rule out head bleed and left shoulder fracture (break in the bone). The ED Provider Note i[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was cognitively impaired (trouble remembering, learning new things, concentrating,), identified as a high fall risk, and had a history of falls, the facility failed to: - Identify interventions related to Resident 1's specific risks and causes to try and prevent the resident from falling, per facility policy Falls and Fall Risk, Managing, -Ensure the interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meets to assess the appropriate level and number of staff required to supervise Resident 1 and identify interventions and means of mitigating the risk of fall for Resident 1. These deficient practices resulted in Resident 1 having an unwitnessed fall on 7/6/2023 and 8/3/2023 and developed an acute to subacute right intertrochanteric femoral fracture with mild posterior displacement (broken right hip) and required surgery to repair the right hip fracture. Findings: A review of Resident 1's admission Record indicated the resident was re-admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition where the body cannot pump blood well enough to give the body a normal body supply), end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean the body's blood when the kidneys are not able to), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and long term use of anticoagulants (medication that helps prevent blood clots). A review of Resident 1's Care Plan initiated 5/23/2023 indicated, the resident was at risk for falls due to episodes of forgetfulness, trying to get up by herself, and not using the call light. The Care Plan interventions indicated to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan interventions indicated Resident 1 needed prompt response to all requests for assistance and to ensure Resident 1 was wearing appropriate footwear (non-skid) / socks when ambulating or mobilizing in the wheelchair, follow fall protocol, and a safe environment with even floors free from spills and or clutter, adequate glare-free night light, a working and reachable call light, the bed in low position at night, and having personal items within reach. A review of the Morse Fall Scale form (an assessment tool used to predict the resident's potential for experiencing a fall) dated 6/1/2023, indicated Resident 1 scored a 65, as a score of 45 or greater indicated a high risk for falls. The Morse Fall Scale form indicated Resident 1 had a history of falling and exhibited a weak gait (resident may shuffle and steps were short). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 6/7/2023, indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required), required extensive assistance and one-person physical assistance for bed mobility, transferring, locomotion (movement) on/off unit, dressing, and toilet use. The MDS indicated Resident 1 required limited assistance and one-person physical assistance for personal hygiene; and supervision and set up help for eating. The MDS further indicated Resident 1 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, and surface-to-surface transferring. The MDS further indicated Resident 1 normally used a walker and wheelchair; and was frequently incontinent (having no voluntary control) of urine and always incontinent of bowel. According to a review of Resident 1's Morse Fall Scale dated 6/27/2023, the resident scored 85, as a score of 45 or greater indicated a high risk for falls. The Morse Fall Scale form indicated Resident 1 had history of falling, exhibited a weak gait, and the resident overestimated or would forget her limits. A review of Resident 1's Change of Condition (COC) documentation dated 7/6/2023 at 4:30 PM, indicated Resident 1 claimed she had a fall but could not specify the day and location. The COC indicated Resident 1 complained of pain to the right side of her face with noted maroon/purplish discoloration of the periorbital (skin surrounding the eye) area of the right eye and mid-forehead. The COC indicated Resident 1's clinician was notified with recommendations for an x-ray of the skull, monitor discoloration, and continue neuro checks per facility protocol. A review of Resident 1's care plan initiated 7/6/2023, indicated Resident 1 claimed she had a fall and the interventions were for Resident 1 to have a tab alarm in bed/wheelchair to alert staff of the resident getting out of bed unassisted, neurological assessment per facility protocol for 72 hours, and a stat x-ray to skull. A review of the Physician's Order dated 7/6/2023, indicated Resident 1 was to have a low bed with floor mats to prevent injury secondary to the resident trying to get out of bed unassisted. According to a review of Resident 1's x-ray of the skull results signed 7/7/2023 at 1:41 PM, it was an unremarkable examination. A review of Resident 1's care plan initiated 7/25/2023, indicated the resident was trying to get out of bed or chair without assistance and had episodes of forgetfulness. The care plan interventions indicated to frequently cue Resident 1, monitor the resident for episodes of getting out/up and redirect behavior, move the resident to a room closer to the station to provide easy visibility/cueing, ensure the tab alarm was applied and functioning well, to keep the bed in lowest position at all times and ensure the floor mats were in place. A review of Resident 1's COC documentation dated 8/3/2023 at 2:45 PM, indicated the resident had an unwitnessed fall and denied pain. A review of Resident 1's Pain assessment dated [DATE] at 3:06 PM, indicated Resident 1 denied pain and upon assessment could move all extremities with no complaints of pain. A review of Resident 1's COC documentation dated 8/3/2023 at 5:48 PM, indicated Resident 1 had an episode of screaming and yelling with complaints of severe throbbing pain to the right hip, right thigh, and right heel. The COC indicated Acetaminophen (pain medication) was administered to Resident 1 but was not effective in relieving the resident's pain. A review of the Physician's Order dated 8/3/2023, indicated to transfer Resident 1 to GACH 1 to rule out limb threatening ischemia (inadequate blood supply) to the right lower extremity. According to a review of GACH 1 Computed Tomography Angiogram (CT scan, detailed images of the body that uses a dye to create pictures of blood vessels) of the lower extremity dated 8/3/2023 at 11:16 PM, Resident 1 had an acute to subacute right intertrochanteric femoral fracture with mild posterior displacement (broken right hip). A review of GACH 1 Physician Progress Note indicated on 8/7/2023 Resident 1 received right hip fracture repair with intramedullary nail (a surgical rod forced into a long bone of the extremities that acts as an immobilization device to hold the two ends of the fractured long bone in position) surgery. During an observation on 8/17/2023 at 2:57 PM, Resident 1 was lying on her back in bed with the bed position low and floor mats to the left and right side of the bed. During a concurrent interview, Resident 1 stated she was in the hospital last week because she had an operation on both hips. During an interview on 8/17/2023 at 3:58 PM, Certified Nursing Assistant (CNA) 1 stated Resident 1 frequently tried to get out of bed and had a bed alarm, but sometimes when staff check the resident, she was already sitting at the side of the bed. CNA 1 stated Resident 1 needed assistance with walking and was confused most of the time. A review of the facility's Policy and Procedure titled, Care Plan, Comprehensive Person-Centered, revised 12/2016, indicated the interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. During an interview on 8/17/2023 at 4:30 PM, the Director of Nursing (DON) stated there was no IDT meeting held for Resident's 1 COC on 8/3/2023. During an interview on 8/22/2023 at 2:14 PM, Registered Nurse Supervisor (RNS) 3 stated she was working on 8/3/2023 when Resident 1 fell. RNS 3 stated Resident 1 was found on the floor by Licensed Vocational Nurse (LVN) 2. RNS 3 stated Resident 1 did not like to use the call light and had very impulsive behavior. RNS 3 stated Resident 1 did not have a sitter but needed one to prevent falls. RNS 3 stated the current solution was to place Resident 1 near the nurse's station. During an interview on 8/22/2023 at 2:22 PM, LVN 2 stated he was working on 8/3/2023 when he heard Resident 1's bed alarm again and went and helped her back to bed. LVN 2 stated Resident 1 was usually alert with episodes of confusion, tried to get out of bed all the time, was impulsive, and did not use the call light. On 8/22/2023 at 2:45 PM, during an interview, CNA 2 stated she remembered Resident 1 coming back from dialysis on 8/3/2023 and Resident 1 tried to get out of bed. CNA 2 stated she helped Resident 1 back to bed a couple of times that day. CNA 2 stated Resident 1 never used the call light, and she would help Resident 1 to the chair. CNA 2 stated Resident 1 did not have a sitter but should have one because she always tried to get out of bed. During a telephone interview on 8/22/2023 at 4:20 PM, Resident 1's Family Member (FM) stated the resident had a history of falls and was always trying to get out of bed. The FM stated she was informed of Resident 1's fall on 8/3/2023 but stated she had not had an IDT meeting with the facility regarding Resident 1's plan of care after the resident fell on 8/3/2023 or when she was re-admitted to the facility. A review of Resident 1's Resident Care Conference documentation indicated there were no resident care conferences / IDT meetings documented for Resident 1's COC regarding falls on 7/6/2023 and 8/3/2023. During an interview on 8/23/2023 at 9 AM, the Medical Records (MR) staff stated the only IDT meeting for Resident 1 was dated for 6/9/2023. During an interview on 8/23/2023 at 9:04 AM, Registered Nurse Supervisor (RNS) 3 stated IDT meetings were usually done after an incident like a fall, or a complaint. During a concurrent interview and record review on 8/23/2023 at 9:08 AM, Resident 1's Resident Care Conference documentation was reviewed with Social Services (SS). SS stated IDT meetings were done quarterly, if the resident or family members had issues, on admission if there were concerns, and with a change of condition. SS stated that he was part of the IDT meetings and an IDT meeting for Resident 1 was not held after her COC on 7/6/2023 or 8/3/2023. SS stated according to the facility's policy an IDT meeting should have been held with Resident 1's family after the resident had a change of condition. SS stated the purpose of an IDT meeting was to discuss the resident's plan of care, the family's concerns, and to give updates to family members on the plan of care. SS stated if an IDT was not held there was a potential for the resident concerns and plan of care to not be addressed. During a concurrent interview and record review on 8/23/2023 at 9:20 AM, Resident 1's Resident Care Conference documentation was reviewed with Registered Nurse Supervisor (RNS) 2. RNS 2 stated not conducting an IDT meeting can lead to the resident not receiving updated care after a change in condition. RNS 2 stated Resident 1 needs to be monitored closely due to the resident's impulsive behavior and attempts to get out of bed to keep the resident safe from falls. A review of the facility's Policy and Procedure titled, Falls and Fall Risk, Managing, revised 3/2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling .Resident conditions that may contribute to the risk of falls include fever, infection, delirium and other cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypotension, functional impairments, visual deficits, and incontinence .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarm will be monitored for efficacy and staff will respond to alarms in a timely manner .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue to change the current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents was free from verbal abuse, when Licensed Vocational Nurse 1 (LVN1) yelled and spoke loudly to Resident 1. This deficient practice resulted in Resident 1 suffered emotional distress which affected her psychosocial well-being resulting in Resident 1 losing sleep, crying, feeling fearful and unsafe, and feeling like a child. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty or discomfort swallowing) following cerebral infarction (damage to the brain due to a loss of oxygen to the area), and a gastrostomy (a tube inserted through the wall of the abdomen to the stomach, which may be used for feeding). A review of the physician`s history and physical dated 10/19/22, indicated Resident 1 had the capacity to make decisions. A review of Resident 1's most recent Quarterly Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/9/23, indicated Resident 1 had intact cognition evidenced by consistent and reasonable decisions. The MDS further indicated Resident 1 was totally dependent on staff for toilet use, and eating, and required extensive assistance with one-person physical assistance for dressing, bed mobility, and personal hygiene. A review of the staff assignment sheet dated 4/29/23 for 11 PM to 7 AM shift, indicated LVN1 was assigned to Resident 1. During an interview on 5/10/23 at 10:24 AM, Resident 1 stated LVN1 yelled at her not only once but multiple times. Resident 1 stated, On 4/30/23 at around 2 am when LVN1 yelled at me, I told him don't yell at me, I am not your child. Resident 1 stated LVN1 talks loudly all the time, but he yelled at me on 4/30/23. He told me I don't like you and I told him I am going to report you. Resident 1 was observed crying. Resident 1 stated That night I told Registered Nurse Supervisor 1 (RN1) that LVN1 yelled at me, and I do not want him to come back. Why would I want a person who does not like me to take care of me. I did not want the registry (a list of nurses who are legally licensed and trained to practice nursing) CNAs to come back either. Resident 1 further stated Next day I told LVN2 about the incident. Resident 1 was observed crying again. Resident 1 stated I even told my family about the way LVN1 treated me. From day one of my stay in the facility, LVN1 did not like me. When he was assigned to me at nights, I did not sleep. I had to stay awake and watch everything that he was doing. Resident 1 stated I was scared to tell the staff that I do not want LVN1 to take care of me. Resident 1 stated she is alright now. She stated she has better sleep at night knowing LVN1 is no longer taking care of her. A review of the facility's written Investigation Report dated 5/4/2023, indicated Resident 1 reported to LVN2 regarding the alleged verbal abuse towards her by LVN1 on 4/30/2023 at 9:45 PM. Resident 1 reported that On 4/30/2023 around 2:30 AM, two Certified Nursing Assistants (CNA) from the registry (staff personnel provided by a placement service on a temporary or on a day-to day basis) were cleaning me. The CNA that was helping my nurse took the pillow from underneath my left arm. I asked my CNA to return my pillow, but she said I did not have a pillow there for her to return. Then, the CNA left and came back with LVN1. LVN1 started yelling at me and saying, I listened to the way you treat my CNAs. Resident 1 stated LVN1 does not like me, and I am not his child. This was not the first time he yelled at me. The investigation report further indicated that Resident 1`s roommate verified that the incident Resident 1 reported, did occur and LVN1 did in fact yell at her. The facility`s investigation report indicated that several residents stated LVN1 raises his voice, yells at other residents, and gets agitated easily. The facility`s conclusion of the allegation of verbal abuse by LVN1 indicated that the verbal abuse did occur, and the facility will not tolerate any type of verbal abuse towards their residents. On 5/4/2023, LVN1 was terminated. During an interview on 5/10/23 at 9:40 AM, The Administrator (ADM) stated the alleged abuse incident happened on 4/30/2023 at around 2:30 AM. The ADM stated that Resident 1 was being changed by two registry CNAs and she requested her left arm pillow to be returned underneath her arm. One of the CNAs stated there was no pillow originally and Resident 1 insisted there was. Thereafter, CNA left the room and came back with LVN1. The ADM stated based on Resident 1`s report, LVN1 yelled at her and treated her like a child. The ADM sated LVN1 generally speaks with a loud voice. The ADM further stated there have been other incidents that facility staff members have had issues with LVN1`s speaking loudly. The ADM stated LVN1 talks loudly and in a commanding way, and the Director of Nursing (DON) and I had previous conversations regarding this matter with him. The ADM stated on 4/30/23 at around 9:45 PM, Resident 1 reported to LVN2 that LVN1 yelled at her. The ADM stated LVN2 called me that night. The ADM stated, I came to the facility on 5/1/23 around 6 AM and that's when I had a conversation with LVN1, and I told him that I need to start an investigation regarding this incident, and I suspended him for three days. During an interview on 5/10/2023 at 12:04 PM, LVN2 stated Resident 1 is very alert, and has slurred speech (not being able to pronounce each word clearly). LVN 2 stated I worked on Sunday 4/30/2023 during the 3PM-11PM shift and I was assigned to Resident 1. At around 9:45 PM, Resident 1 stated that the night before she was having a disagreement about a pillow with the CNAs. She also told me that LVN1 yelled at her because of the disagreement with the CNAs. LVN2 stated LVN1 is a big guy, normally he has a big tone, he could get loud. LVN2 stated Resident 1 was crying when she was telling me about the incident. LVN2 stated I reported the alleged verbal abuse incident to the Administrator that night around 10 PM. LVN2 stated Resident 1 was emotionally affected because of LVN1 yelling at her. During an interview on 5/10/23 at 12:48 PM, the DON stated, LVN1 is tall, and his voice is husky and loud and some residents get intimidated because of his voice. The DON stated there are some residents who do not like LVN1 because of his voice. The DON stated The ADM and I talked to LVN1 about his voice. We told him he needs to lower his voice. We are nurses and we must really adjust ourselves, we cannot say this is my voice. The DON stated LVN1 received previous in-services regarding customer service, and elder abuse. During an interview on 5/10/2023 at 1:10 PM, the Director of Staff Development (DSD) stated LVN1 was terminated. DSD stated Sometimes some people think LVN1 was mad or angry but that was the way he talks. The DSD stated, The management decided to let LVN1 go, because residents complain that LVN1 treats them like a child. During an interview on 5/11/23 at 11:17 AM, Family 1 stated Resident 1 reported to her that LVN1 is not attending to her needs. Family 1 stated Resident 1 was unhappy with the way LVN1 talked to her. Family 1 stated Resident 1 reported to her that LVN1 raised his voice at her, and she felt uncomfortable. Family 1 stated Resident 1 was very emotional and very tearful with me when she told me about the incident that happened on 4/30/23. She could barely get the words out of her mouth because every time she was trying to explain, she got more and more distraught. Family 1 stated Resident 1 did complain about not being able to sleep occasionally when LVN1 was taking care of her. Family 1 stated whenever LVN1 would scream at her or he would not provide her requested assistance, she was not able to sleep well. Family 1 stated It is hard for Resident 1 to let it go; it is hard for her to recover from this anxiety that she was going through. Family 1 stated part of this is because of Resident 1`s condition, from a total independent person for all her life to a total dependent person. Family 1 stated If you wanted to understand Resident 1, you are able to. LVN1 did not want to understand Resident 1. I hate to say if it was a cultural thing, but you have to want to understand and want to help people. During a telephone interview on 5/12/23 at 10:48 AM, CNA2 stated I remember on 4/30/23, I was working in the facility during the 11PM-7AM shift. RN1 switched my assignment and assigned Resident 1 to me because Resident 1 was not happy with her previous CNA. I remember that when I changed Resident 1, I called LVN1 to assist me to pull her up. I saw Resident 1 turn her face away from LVN1 when he was at her bedside. I asked her why you turned your head, she said LVN1 doesn't like me. During a telephone interview on 5/12/23 at 11 AM, CNA 4 stated she worked in the facility on 4/29/23 during the 11PM-7AM shift, and she was assigned to Resident 1. CNA4 stated At around 2 AM, when we were changing Resident1, Resident 1 asked me to put the pillow back under her left arm. I told her that there was no pillow there, but I can get her one. Resident 1 was not satisfied with the way we placed the pillow under her left arm. I tried different ways to assist her, but she was not satisfied. We decided to ask LVN1 to help us understand Resident 1. CNA4 stated LVN1 came to Resident 1`s room and spoke to her in a strict manor, his voice was high tone, commanding and demanding, as if he was talking to a child. LVN1 told Resident 1 I do not like the way you treat my CNAs. CNA4 stated a charge nurse should never talk to any resident the way LVN1 talked to Resident 1. CNA4 further stated she did not like the way LVN1 spoke to Resident 1. CNA4 stated LVN1 instructed me to leave the room. CNA4 stated when I returned to the room, Resident 1 was not talking anymore. She was emotionally affected by the way LVN1 talked to her. She just told me that she does not want LVN1 to come back to her room. During an interview on 5/12/23 at 12 PM, the ADM stated LVN1 quit on his own. The ADM stated on 5/4/23, when LVN1 came to the facility, we were going to discuss the incident with him, but he immediately stated, I do not want to talk about this, I already have a job and I just need to go, I have to go. LVN1 had a loud commanding voice. LVN1 talking to Resident 1 in a loud commanding voice was not right. We do not talk to the residents like that. My plan was to talk to LVN1 and address this issue. The ADM stated, I do not know what the definition for verbal abuse is, but I just want good customer service for our residents, and I was not happy with the way LVN1 spoke to Resident 1. The ADM stated, I did not know that other residents also had issues with the way LVN1 talks to them until we investigated Resident 1`s complaint. A review of the facility's Elder Abuse In-service Records indicated LVN1 received Elder Abuse training on 2/7/2023. A review of LVN1`s Annual Employee Performance dated 2/9/2023, conducted by the facility`s DON indicated LVN1 was advised to speak calmly, respect the residents, and lower the tone of his voice to improve his performance. A review of the facility`s policy and procedures titled Abuse Prevention Program, revised August 2006, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment (A physical punishment used as a means to correct or control behavior which includes, but is not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object), and involuntary seclusion (Separation of a resident from other residents or from her/his room or confinement to her/his room [with or without roommates] against the resident's will, or the will of the resident representative). Our facility is committed to protecting our residents from abuse by anyone, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, or any other individuals. Our abuse prevention program provides policies and procedures that govern, as a minimum mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting abuse, stress management, dealing with violent behavior or catastrophic reaction.