**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for one of five sampled residents (Resident 1), when Resident 1 had one documented weight on 6/6/25 since being admitted to the facility on [DATE]. Staff did not complete a weight on admission and weekly as ordered by the physician, Resident 1 was not consuming meals to its entirety or refused meals, the facility was aware of Resident 1's refusal to be weighed and the Restorative Nursing Assistant (RNA) did not follow up with the licensed nurses.This failure resulted in a 16% weight loss of 21.2 pounds (lbs.) in two (2) months placing Resident 1 at risk for unmonitored significant weight loss that could have worsened Resident 1's diagnosed heart condition and placed her at risk for inadequate nutritional intake.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis of congestive heart failure (condition in which the heart doesn't pump blood as it should), Dementia (loss of memory, language and other thinking abilities), osteomyelitis (inflammation of a bone caused by infection), Diabetes Mellitus (DM- increased sugar in the blood).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/20/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a telephone interview on 8/12/25 at 12:00 p.m. with family member (FM) 1, FM 1 stated, there were concerns regarding Resident 1 refusing meals and possible weight loss. FM 1 stated, Resident 1 had expressed that the facility food did not taste good and therefore Resident 1 did not consume her meals. FM 1 stated Resident 1 appeared to have lost weight since admission to the facility but was unaware how much weight she had lost.During a concurrent observation and interview on 8/12/25 at 1:01 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed lying in bed appearing thin and frail. Resident 1 stated she had resided in the facility for a few months. Resident 1 stated she disliked the food in the facility and would consume a small portion or none of the food served during mealtimes. Resident 1 stated she was unaware if the facility staff had noticed weight loss or weight gain since admission and stated she was unaware if she had experienced weight loss during her stay.During a review of Resident 1's, Nutrition Evaluation, dated 5/18/25, the evaluation indicated, . At risk for weight fluctuations r/t PO [related to by mouth] intake, DM, and diuretic (medication used to eliminate excess fluid buildup in the body) therapy. Resident with obesity which can have a negative effect on their health, including but not limited to altered cardiac output, fluid retention, altered blood sugars, ineffective breathing patterns. estimated total daily 1544-1930 calories, protein intake daily 77-93 gram (g). The evaluation indicated the nutritional evaluation was completed by the Registered Dietitian (RD) and documented risks for weight fluctuations after review of Resident 1's evaluation.During a record review of Resident 1's, Order Summary, dated 8/19/2025, the order summary indicated, . Weekly Weights one time a day every Fri (Friday) for Admission.During a review of Resident 1's Electronic Medical Record (EMR) titled, Weights, the EMR indicated, Resident 1 had a documented weight of 130 pounds on 6/6/2025. The document indicated there were no other weights documented on the EMR since admission on [DATE].During a review of the facility's handwritten document titled, Daily weights, dated 5/15/25 for Resident 1, the document indicated, Resident 1 had refused weights from 5/15/25 to 6/3/25, 6/5/25, 6/26/25 to 7/7/25. The document did not indicate any further attempts for weight check after 7/7/25. The document did not indicate if the nurse or physician was made aware of Resident 1's refusals. Concurrent review of the document and Resident 1's EMR indicated there was no documentation or evidence indicating the nurse and the physician were made aware of Resident 1's refusals and multiple attempts to re weigh.During a concurrent interview and record review on 8/12/25 at 1:40 p.m. with licensed vocational nurse (LVN) 1, Resident 1's electronic medical record (EMR) was reviewed, including document titled Weights. The document indicated Resident 1 was only weighed on 6/6/2025 since the admission to the facility and there were no other weights documented in the EMR. The EMR indicated there was no documentation indicating Resident 1 had refused to be weighed by the restorative nursing assistant (RNA). LVN 1 stated Resident 1 should have documented weight checks monthly. LVN 1 stated if Resident 1 had refused to be weighed, the RNA who was assigned to weigh all residents, should have notified the nurse. LVN 1 stated the facility process included documentation of missed weights, physician and resident representative notification.During an interview on 8/12/25 at 2:43 p.m. with RNA 1, RNA 1 stated, part of the RNA duties was to complete weekly and monthly weights for every resident in the facility. RNA 1 stated the RNAs' would receive a list of all residents who needed to be weighed monthly and weekly from the MDS nurse. RNA 1 stated, once the weights were completed and recorded on the list provided by the MDS nurse, the completed list was given back to the MDS nurse who would document the weights obtained in the residents EMR. RNA 1 stated there had been no resident refusals for the month of August 2025 and all residents including Resident 1, should have been weighed. RNA 1 stated, if a resident refused to be weighed, it should have been documented on the list and notified the MDS nurse. RNA 1 stated the facility process was for every resident to be weighed on admission, 24 hours after admission, weekly for four weeks after admission, then monthly unless the physician orders otherwise.During a concurrent interview and record review on 8/12/25 at 2:51 p.m. with the director of staff development (DSD), Resident 1's document titled, Weights, dated 6/6/25 and Resident 1's electronic medical record (EMR) were reviewed. The document indicated Resident had a documented weight of 130 pounds on 6/6/2025 and no other documented weights since admission. The EMR indicated there was no documentation indicating Resident 1 had refused to be weighed by the RNA. The DSD stated all residents should have been weighed in the facility on admission, 24 hours after admission, weekly for four weeks after admission, then monthly unless the physician orders otherwise. The DSD stated if Resident 1 had refused to be weighed by staff, the nurse should have documented the refusal in the EMR. The DSD stated, based on the lack of documentation indicating Resident 1 had refused to be weighed by the RNA in Resident 1's EMR, there was no way to definitively say if Resident 1 had weight loss or weight gain since admission.During a concurrent telephone interview and record review on 8/12/25 at 2:58 p.m. with the Registered Dietitian (RD), Resident 1's document titled, Weights, dated 6/6/25, and Resident 1's, Nutrition Evaluation, dated 5/18/25 were reviewed. The document weights indicated Resident 1 had a documented weight of 130 pounds on 6/6/2025. The document Weights indicated there were no other documented weights since admission. The evaluation indicated, . At risk for weight fluctuations r/t PO intake, DM, and diuretic therapy. Resident with obesity which can have a negative effect on their health, including but not limited to altered cardiac output, fluid retention, altered blood sugars, ineffective breathing patterns. The RD stated Resident 1's nutrition evaluation was completed on admission and resident was weighed to reflect the current weight status at the time of assessment. The RD stated nutrition assessments were completed every three months and as needed if there were changes. The RD stated the facility process was for the nursing staff to identify any weight loss, meal preference changes or refusal of meals. The RD stated if there was a concern, the nursing staff would notify the dietary supervisor. The RD stated the facility process was for the staff to offer resident alternatives and communicate with the dietary supervisor of the changes in meal consumption. The RD stated if Resident 1 was refusing meals and weight checks, the nursing staff should have documented the occurrences and attempted to trigger an alert for all staff to be made aware that there was a potential problem. The RD stated there was no documentation reflecting refusals of weight checks and meals from the record review at this time. The RD stated the facility process was to identify residents who were experiencing weight loss and include them in the weekly weight committee where residents would be monitored closely to avoid weight changes if possible.During an interview on 8/12/25 at 3:14 p.m. with the dietary services manager (DSM), the DSM stated the facility process was for the nursing staff to monitor Resident 1's meal intake and weight checks. The DSM stated if there was a change in food preferences or changes in meal consumption, it was the nursing department's responsibility to inform the DSM of the changes. The DSM stated she had not received any complaints or reports indicating Resident 1 was refusing meals and losing weight. The DSM stated she was part of the weight loss committee that met on a weekly basis to discuss residents who were at risk for weight fluctuations. The DSM stated Resident 1 was not part of the group of Residents that were being monitored for weight and nutrition concerns. The DSM stated Resident 1 should have been monitored and staff should have documented the refusal of weight checks and meals to incorporate Resident 1 into the weight loss committee to monitor her weight loss closely.During a review of Resident 1's, Nutrition Care Plan, dated 5/16/25, the care plan indicated, . [Resident 1] has a diet order. Controlled Carbohydrate Diet (CCD) Soft and Bite sized texture, Thin Liquid consistency, Goal: The resident will maintain adequate nutritional status as evidenced by maintaining weight, no signs and symptoms of malnutrition. Interventions: Provide, serve diet as ordered. Monitor intake and record q meal.During a review of Resident 1's, Noncompliance Care Plan, dated 5/16/25, the care plan indicated, . [Resident 1] is resistive to care noncompliant. being weighed r/t adjustment to nursing home. Goal: [Resident 1] needs will be met by staff daily.During an interview on 8/12/25 at 3:37 p.m. with the director of nursing (DON), the DON stated the facility process was for all residents to have been weighed on admission and then monthly, unless the physician ordered residents to be weighed more often. The DON stated Resident 1 should have been weighed as ordered and if Resident 1 had refused to be weighed by staff, the nurse should have documented the refusal in the EMR. The DON stated the problem was the staff were writing the weights on a list provided by the MDS nurse, but the refusals were not being documented in the EMR to reflect the attempts. The DON stated as a result, staff were not aware if Resident 1 had gained or lost weight. The DON stated there should have been progress notes or a documented refusal to alert the staff to monitor Resident 1 closely. The DON stated, moving forward, the facility will be implementing a new system to assist with documenting all weights and refusals by the residents.During a telephone interview on 8/12/25 at 3:43 p.m. with the MDS nurse, the MDS nurse stated the list of residents to be weighed was provided to the RNAs. The MDS nurse stated once the RNA completed the weights, the list would be given back to the MDS nurse to be reviewed. The MDS nurse stated it was the RNA's responsibility to document and inform the nurse of residents' weights and refusals. The MDS nurse stated, once the list of completed weights was reviewed, the list would be discarded, and there were no other paper records for the weights that were completed. The MDS nurse stated it was the nurse's responsibility to ensure weights were documented in the EMR and all refusals were addressed. The MDS nurse stated it was also the nurse's responsibility to document the refusal and attempts to re-weigh the resident. The MDS nurse stated that the monthly weights were reviewed for the month of August 2025, but there were no refusals to be weighed by any resident. The MDS nurse stated she was not aware of Resident 1's refusal to be weighed every month.During a telephone interview on 8/22/25 at 3:30 p.m. with the DON, the DON stated the facility obtained a current weight for Resident 1 on 8/21/25. The DON stated Resident 1's current weight was 108.8 lbs. The DON stated Resident 1 had a physician order for weekly weight checks that was initiated on admission but was not completed. The DON stated Resident 1 had a significant weight loss of 16% from the previous weight checked on 6/6/25 of 21.2 lbs.During a review of the Resident 1's, Diet Order, dated 5/23/25, the order indicated, . Consistent Carbohydrate (CCD) diet soft and bite sized texture, thin liquid consistency.During a review of the document titled, Diet Average Detail Report- Averages for days 1-28), dated 4/18/25, the document indicated, . CCD diet. Protein 91.175 g (gram- unit of measure), and Energy kCal (calories) 2, 066.76 kCal . The document indicated that Resident 1 should have consumed the amount of nutrition listed on a daily average, when Resident 1 consumed 75-100% of all meals.During a review of Resident 1's document titled, Documentation Survey Report-Nutrition- Meal intake, dated 5/2025, 6/2025, 7/2025 and 8/2025. The report indicated the meal intake percentage (0%- Refused meals completely or consumed one or two bites, 25%-a small amount was consumed, 50% approximately half of food is consumed, 75%- Majority of the food is consumed but one or more items are left, 100%- all meal is consumed) for breakfast, lunch and dinner. The document indicated Resident 1 consumed: May 16th-31st 2025: Resident 1 ate 25% or less, approximately 258 calories and 11 grams of protein for 10 meals out of 45 with four of those meals' resident refused. Resident 1 ate 25 to 50% and approximately 775 calories and 34 grams of protein for 17 meals (38% of the time). Resident 1 ate 51 to 75%, approximately 1300 calories and 56 grams of protein for 18 meals (40% of the time). June 1st- 30th 2025: Resident 1 ate 26 to 50% and approximately 775 calories and 34 grams of protein for 48 meals (53% of the month). Resident ate 0 to 25% and approximately 258 calories and 11 grams protein for 9 meals. Resident 1 refused meals 18 times and ate 0 to 25% for 9 meals. Resident 1 ate between 51 to 75%, approximately 1300 calories and 56 grams of protein for 12 meals out of 90 in the month. July 1st- 31st 2025: Resident 1 ate 0 to 25%, approximately 258 calories and 11 grams of protein for 28 meals in the month or 30% of the time. Resident 1 ate 26 to 50%, approximately 775 calories and 34 grams of protein for 31 meals in the month or 33% of the time and refused meals 20 times. Resident 1 ate 51 to 75% for 9 meals (9.7% of the time) in the month. August 1st- 31st 2025: Resident 1 refused meals 43 times (46% of the time). Resident 1 ate 0 to 25%, approximately 258 calories and 11 grams of protein for 20 meals (21.5% of the time). Resident 1 ate 26 to 50%, approximately 775 calories and 34 grams of protein for 20 meals in the month of August. Resident 1 ate 51 to 75 % for 5 meals. The document indicated there was no documented meal intake recorded for breakfast on 5/29/25 & 6/4/25, lunch on 5/25/25, 5/29/25, 6/4/25, & 8/9/25, dinner on 7/9/25 & 7/31/25, therefore there was no indication of the nutritional intake Resident 1 received for the undocumented dates. During a record review of the facility's policy and procedure (P&P) titled, Weights, dated 8/28/2020, the P&P indicated, . The Center uses weights as one component of data collection needed to evaluate resident's nutritional status, fluid retention, or diuresis. Weighing Criteria, New Admits, weigh the day of admission then weekly for one month, if weights and nutritional status are stable after one month, weigh the resident monthly. Weekly Weights, the following are guidelines for residents who may need to be weighed weekly (not all inclusive): Food intake has declined and persisted, Slow trending of weight loss/gain. New or altered diuretic schedule (unless physician orders more frequently). Multiple Stage II and any Stage III or IV pressure ulcers. Significant change of condition. Re-weigh. When the Nutrition Hydration Skin Committee or designee reviews the weights, the Committee determines which residents are evaluated. The team or designee reviews the resident's status and makes recommendations. Obtaining and Recording Weights: Weights are obtained by nursing personnel designated by the Director of Nursing Services. The staff member weighing the resident records the weight on the Weight Worksheet. The nurse reviews the current weight and compares it to prior weight on Weight Worksheet. The nurse requests a re-weigh in accordance with the re-weigh definition outlined above. The nurse records validated weights on the Weight Record in the resident's medical record. Licensed nurses will notify physician, resident/responsible party of significant change in weight and document notification in progress notes. Progress note to include responses.During a professional reference review retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892745/pdf/nihms156446.pdf, Patterns of Weight Change Preceding Hospitalization for Heart, dated October 2007, indicated, . Increases in body weight are associated with hospitalization for heart failure and begin at least [one] week before admission. Daily information about patients' body weight identifies a high-risk period during which interventions to avert decompensated heart failure that necessitate hospitalization for Heart Failure . Frequent monitoring of heart failure patients' clinical status, specifically their body weights, can alert clinicians to the early stages of heart failure decompensation. By focusing on weight changes, clinicians would be well positioned to implement interventions that could prevent decompensation of heart failure that necessitates hospitalization .During a review of professional reference titled, Practice Paper of the American Dietetic Association, dated 2010, indicated, . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association). During a review of a professional reference publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated, . The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three residents, (Resident 1), when Resident 1 was admitted on [DATE] with history of abnormalities of gait and mobility, assessed with severe cognitive impairment and the need for assistance with mobility, and experienced falls on 11/7/24, 11/8/24, 11/11/24, 11/14/24 and 11/15/24 and did not provide supervision and effective interventions to prevent falls in accordance with policies and procedures and professional standards of practice. These failures failure resulted in Resident 1 obtaining an acute, mildly displaced left intertrochanteric and subtrochanteric fractures (type of break in the bones near the hip) following the 11/15/24 fall and causing Resident 1 to undergo open reduction and external fixation (ORIF- surgical procedure that treats broken bones by inserting implants), avoidable pain and suffering, hospitalization from 11/15/24-11/18/24 and ongoing physical therapy (PT) to regain strength and balance. Findings : During a review of Resident 1's admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for syncope (fainting), repeated falls, orthostatic hypotension (low blood pressure that occurs when standing or sitting), Parkinson ' s disease (disorder that causes nerve cells in the brain to weaken or die), abnormalities of gait (walking) & mobility , bradycardia (slow heart beat), dizziness, muscle weakness, gout (causes joint pain and swelling due to uric acid build up), mood disorder, shortness of breath, hyperuricemia (condition of too much uric acid in the blood), hypertension (high blood pressure), cerebral aneurysm (a bulge in a blood vessel in the brain), arthritis (painful inflammation and stiffness of the joints). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 11/11/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 4 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s document titled, Incident by Incident Type- Falls, dated 12/4/24, the document indicated, Resident 1 had documented falls on 11/7/24, 11/8/24, 11/11/24, 11/14/24 and 11/15/24. During a record review of Resident 1 ' s, Fall Care Plan, dated 11/7/24, the CP indicated, .At risk for fall or injury due to impaired balance, weakness, orthostatic hypotension . During a record review of Resident 1 ' s, Fall Risk Evaluation, dated 11/8/24, the record indicated, Resident 1 had a documented fall risk score of 31 (a score 10 or higher indicates high risk for falls). During a record review of Resident 1 ' s Interdisciplinary Team (IDT- team that consists of various staff that are involved with resident ' s care) Post Fall Meeting, dated 11/8/24, the record indicated, . Resident had two unwitnessed falls that occurred on 11/8/2024 at approximately 2134 (9:34 p.m.) and 0440 (4:40 a.m.) . IDT recommendations fall mat to right side of bed- room change closer to nursing station for visibility- placed of fall program 11/8 . During a record review of Resident 1 ' s, Behavior Care Plan (CP), dated 11/8/24, the CP indicated, . behavior symptoms, non-compliance continuously removing brief, impulsive behavior continuously attempting to self-transfer, crawling out of bed and preferring to lay on floor . During a record review of Resident 1 ' s, Functional abilities section-GG, dated 11/11/24, the record indicated, Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting, dressing, lying/sitting on side of bed, sit to stand and transfers wheelchair/bed. During a record review of Resident 1 ' s, IDT Post Fall Meeting, dated 11/14/24, the record indicated, . Resident had a witnessed fall that occurred 11/14/24 . continue with 30-minute checks, staff to assist resident with toileting after meals and at bedtime. Continue on fall program . During a review of Resident 1 ' s, Fall Care Plan, dated 11/14/24, the record indicated, . witnessed fall on 11/14/24 . interventions, 1 on 1 (staff member assigned to care for resident at all times) staff observation . During a record review of Resident 1 ' s, Post Fall Risk Evaluation, dated 11/14/24, the record indicated Resident 1 ' s fall risk score was 26 (Score 10 or higher indicated the resident is at high risk of fall). During a record review of Resident 1 ' s Clinical Alert, dated 11/15/24, the record indicated, CNA come at 7:30 a.m. went to the nurse got report what patient was on 1 on 1 CNA went to the doorway and saw the patient getting up and witness the patient fall . During a record review of Resident 1 ' s, Nurses Note, dated 11/15/24, the note indicated, . Resident was attempting to sit on her wheelchair when she slipped and fall hitting her head on the wall as per the CNA that witnessed the fall. Resident helped off the floor to the bed. An assessment was done with no visible cut to the head . Resident later transferred to the hospital . During a record review of Resident 1 ' s, Post Fall Risk Evaluation, dated 11/15/24, the record indicated Resident 1 ' s fall risk score was 17 (Score 10 or higher indicated the resident is at high risk of fall). During a record review of Resident 1 ' s, Emergency department Results, dated 11/15/24, the record indicated, . there is an acute, mildly displaced left intertrochanteric and subtrochanteric fractures . During a review of Resident 1 ' s, Emergency Department Note, dated 11/15/24, the note indicated, . brought in by ambulance (BIBA) from [facility name] for fall. Patient got up to use the restroom using her walker and tripped fell to left side striking left side of head. Patient main complaint is left leg pain . During a review of Resident 1 ' s, Operative Report, dated 11/16/24, the report indicated, . procedure performed open treatment of left intertrochanteric femur fracture with cephalomedullary nailing (form of fixation that restores length, alignment and rotation of the femur) . During a review of Resident 1 ' s, Orthopedic Trauma Progress Note, dated 11/17/24, the note indicated, . post operation day 1 status post left hip ORIF. Plan weight bearing as tolerated to left lower extremity, physical therapy and occupational therapy evaluation and treatment . During an interview on 12/4/24 at 1:04 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated the facility process was for residents who had two or more falls within a 24-hour period, would have been placed on one -to-one care until further notice. CNA 1 stated the purpose of the one-to-one care was to prevent falls and to keep the residents safe. CNA 1 stated when a resident was assigned a one-on-one care, it indicated a staff member was expected to be with the resident at all times. During an interview on 12/4/24 at 1:15 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated it was the facility process to assign one to one care for residents who had two or more falls in a 24-hour period. LVN 1 stated the one-on-one care was implemented to prevent further falls and for resident safety. During a concurrent interview and record review on 12/4/24 at 2:03 p.m. with the director of nursing (DON), Resident 1 ' s, Fall Care Plan, dated 11/14/24 was reviewed. The Fall Care Plan indicated, . Witnessed fall on 11/14/24 . interventions, 1 on 1 staff observation . The DON stated on 11/14/24, Resident 1 was assigned a one-to-one care that began on the afternoon shift from 2 p.m. to 10:30 p.m. The DON stated on the night shift of 11/14/24-11-15/24 from 10:30 p.m. to 7:30 p.m., there was no staff assigned for one-on-one care for Resident 1 until 7:30 a.m. on 11/15/24. The DON stated Resident 1 had a fall on 11/15/24 during shift change at 7:30 a.m. when the night shift staff left and the morning staff began their shift. The DON stated Resident 1 was confused, non-compliant with care and had behaviors that included attempting to get out of bed without assistance. The DON stated Resident 1 had a total of five falls in the facility since admission. The DON stated the facility process was for residents to be put on one-to-one care when the resident had two or more falls in 24-hour period. The DON stated, a staff sould have been assigned 1:1 care to monitor Resident 1 and prevent an avoidable fall on 11/15/2024. During a telephone interview on 12/5/24 at 12:40 p.m. with LVN 4, LVN 4 stated on 11/14/24, Resident 1 was supposed to have a staff member assigned to a one on one care. LVN 4 stated, Resident 1 did not have a staff member assigned prior to Resident 1 ' s fall on 11/15/24. LVN 4 stated the facility process was for a resident who had two or more falls in a 24-hour period, be assigned a staff member for one-to-one care. LVN 2 stated according to the facility policy, Resident 1 should have had a staff member assigned for one on one due to multiple falls and had behaviors that included attempting to self transfer and noncompliance with asking for assistance. LVN 4 stated Resident 1, should have had a staff member present during an avoidable fall that occurred on 11/15/24. During a telephone interview on 12/10/24 at 10:45 a.m. with family member (FM 1), FM 1 stated Resident 1 was able to complete all task while at home including walking and transferring prior to admitting to the facility. FM 1 stated it was not normal for Resident 1 to have had five falls in the facility as Resident 1 was only in the facility for short term rehabilitation. During an interview on 12/11/24 at 10:55 a.m. with registered nurse (RN) 1, RN 1 stated the facility process was for residents with or more falls in 24 hours to have been placed on one-to-one care. RN 1 stated that the process was to inform the DON of all falls and the DON determined when a resident was placed on one-to-one care, 30-minute monitoring or 15-minute monitoring. RN 1 stated apart from the DON, the charge nurse and nurse assigned to resident could have assigned a one-on-one care as needed for the Resident 1's safety. During an interview on 12/11/24 at 11:11 a.m. with LVN 3, LVN 3 stated the facility process for falls was for residents who experience two or more falls in 24 hours be placed on one-on-one care. LVN 3 stated the process was to inform the DON of all falls and the DON would decide who and when would be placed on one-to-one care. LVN 3 stated the one-to-one care could have benefited residents by preventing falls and ensuring safety. During an interview on 12/11/24 at 11:34 a.m. with the administrator (ADM), the ADM stated there was a new fall program implemented for the facility that included revision of the policy. The ADM stated it was the facility expectation for all staff to follow the new implementations related to falls. During a telephone interview on 12/18/24 at 9:01 a.m. with CNA 2, CNA 2 stated that on the morning of 11/15/24, she was called to the facility for a 1 on 1 care for Resident 1. CNA 2 stated she had arrived to the facility between 7:30 a.m. and 8:00 a.m., when CNA 2 arrived she reported to LVN 4 for report and update on Resident 1. CNA 2 stated the morning shift had begun at 6:00 a.m. that morning and when she arrived there was no one assigned to Resident 1. CNA 2 stated after receiving report from LVN 4, she entered Resident 1 ' s room and observed Resident 1 standing and then falling to the floor. CNA 2 stated Resident 1 had behaviors of transferring without assistance, noncompliance and attempting to walk without supervision. CNA 2 stated, Resident 1 ' s fall would have been avoidable if there was a staff member present for 1 on 1 care as assigned. During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 11/2024, the P&P indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The facility recognizes frequent falling to be 2 falls in 30 days. If a resident falls 2 or more times within 24 hours they will be placed one on one supervision for 72 hours and will be reevaluated by IDT for further interventions, if needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received adequate supervision to prevent accidents according to the facility' s policy and procedure (P&P) for one of three sampled residents (Resident 1), when the facility had knowledge of Resident 1' s history of falls and Parkinson's disease (brain disorder that causes uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) on admission and did not provide interventions and supervision to prevent an unwitnessed fall with injury on [DATE] and an unwitnessed fall with injury on [DATE]. These failures resulted in Resident 1 sustaining injuries including dislocation (move from its proper place or position) of the fifth finger of the left hand , Right posterior (back) parafalcine subdural hematoma (collection of blood or bleeding that forms between the brain ' s surface and the covering that occurs after a head injury) a collection of blood), laceration (tearing) to the posterior head and intracranial bleed (bleeding within the skull) with hospitalization in the intensive care unit due to a traumatic brain injury (injury caused by force) and could have contributed to Resident 1's death on [DATE]. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis for . abnormalities of gait (walking) and mobility (movement), muscle weakness, encephalopathy (damage or disease that affects the brain), history of falling, Parkinson ' s disease , sleep apnea (disorder that causes your breathing to stop or get very shallow), hypertension (condition in which the blood vessels have persistently raised pressure) . During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment. During a record review of Resident 1 ' s Fall Risk Evaluation dated [DATE], the assessment indicated, . If the total score is 10 or greater, the resident should be considered at High risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . The evaluation indicated Resident 1 ' s fall risk score was 21. During a review of Resident 1 ' s At risk for Falls Care plan (CP) dated [DATE], the CP indicated, . At risk for fall or injury due to impaired balance, impaired mobility, impaired safety awareness, weakness . assist with activities of daily living (ADL) and mobility needs, ongoing as needed . Fall assessment to be completed on admission, quarterly and as needed, low bed . During a review of Resident 1 ' s Nursing Note dated [DATE], the nursing note indicated, . Patient continues to climb out of bed, refusing to listen to being redirected. Patient appears to be agitated and saying he wants to go home and will go home . During a record review of Resident 1's Nursing Note dated [DATE], the nursing note indicated, .At 0235 (2:35 a.m.) the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . During a concurrent interview and record review on [DATE] at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Nursing Note dated [DATE], was reviewed. The nursing note indicated, .At 0235 the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . LVN 1 stated Resident 1 had an unwitnessed fall on [DATE] causing a dislocation of the left-hand pinky. LVN 1 stated there was no other documentation regarding the fall on [DATE]. LVN 1 stated it was the facility process to document a change of condition, complete a skin assessment and initiate neuro checks for an unwitnessed fall. During a review of Resident 1 ' s Fall Care Plan dated [DATE], the CP indicated, . Fall on [DATE] with injury due to poor safety awareness, non-compliance as evidenced by continuously self-ambulating (walking) without calling for assistance . interventions, neuro-checks every shift for 72 hours from initial occurrence . placed in fall program . The care plan indicated the facility staff did not implement the intervention for neuro checks following Resident 1 ' s fall on [DATE] as documented in the care plan. During a review of Resident 1 ' s Fall Program Care Plan dated [DATE], the CP indicated, . Fall program . blue bracelet, blue fall intervention sign above the head of bed, blue name sign by the door, Non-skid footwear, low bed . During a review of Resident 1 ' s Interdisciplinary Team Note (IDT- team that consists of various staff that are involved with resident ' s care), dated [DATE], the note indicated, . Resident has had episodes of confusion after wife has gone home including non-compliance with care, impulsivity as evidenced by self-transferring and ambulation (walking) without assistance and making false accusations towards staff since admission . During a review of Resident 1 ' s Order Summary Report, dated [DATE], the order summary indicated, . Fall interventions in place: nonskid footwear, low bed every shift . The order summary indicated the facility staff did not implement intervention for nonskid footwear and low bed until three days after the creation of the fall care plan. During a review of Resident 1 ' s Nursing Note dated [DATE], the note indicated, . resident had unwitnessed fall . resident has left side head injury. Pressure applied to the injury. Medical doctor (MD) notified and received order to send to hospital . During an interview on [DATE] at 12:08 p.m. with LVN 2, LVN 2 stated the facility process was to identify residents were a fall risk upon admission and initiate fall precautions, which included bed in low position, non-slip socks and frequent monitoring. Resident 1 ' s fall program was not initiated until 11 days after admission to the facility. LVN 2 stated the facility process for falls was for the charge nurse (CN) to assess the resident for injury, initiate neurological checks, complete a post fall assessment, change of condition assessment, and monitor resident for delayed injury for 72 hours. LVN 2 stated when Resident 1 was exhibiting behaviors that included attempting to self-transfer or ambulating without assistance, it was expected that a 15-minute monitoring would have been initiated or a staff member assigned to monitor Resident 1, but there was no order for these interventions. LVN 2 stated there were interventions that could have been initiated that included floor mats next to bed, redirecting Resident 1 by providing activities or talking, taking Resident 1 to the nurse ' s station for supervision and a one on one for safety. During an interview on [DATE] at 12: 21 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was confused, attempted to self-transfer, unable to use his call light and difficult to re-direct. CNA 1 stated that Resident 1 ' s spouse would visit with Resident 1 approximately 8-10 hours a day and during this time, Resident 1 ' s spouse alerted staff if Resident needed assistance. CNA 1 stated when Resident 1 ' s spouse was in the facility, Resident 1 was calm with no behaviors. CNA 1 stated that when Resident 1 ' s spouse would leave the facility, Resident 1 would exhibit behaviors. CNA 1 stated it would have been beneficial for Resident 1 to have been assigned a one-on-one staff member for his safety. CNA 1 stated it was important to monitor all residents who are a high risk for falls and who exhibit behaviors such as Resident 1, to ensure they are not falling or injuring themselves. During an interview on [DATE] at 12:28 p.m. with CNA 2, CNA 2 stated Resident 1 was confused, unsteady when attempting to stand or walk and at risk for falls. CNA 2 stated that when she was assigned Resident 1, she was afraid he was going to fall due to behaviors of self-transferring and unsteadiness. CNA 2 stated, Resident 1 was wheeled to sit with CNA 2 during most of the morning shift to monitor Resident 1. CNA 2 stated it would have been beneficial for Resident 1 to have had a one-on-one staff member after Resident 1 ' s spouse left the facility, to monitor Resident 1 for his safety. CNA 2 stated it was important to monitor Resident 1 because he had a history of falls. During a concurrent interview and record review on [DATE] at 12:31 p.m. with the Director of Nursing (DON), Resident 1 ' s Fall Risk Evaluation dated [DATE], Nursing Note dated [DATE], Fall Program Care Plan dated [DATE], and Nursing Note dated [DATE] were reviewed. The fall risk evaluation indicated, . if the total score is 10 or greater, the resident should be considered at High risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . The evaluation indicated Resident 1 ' s fall risk score was 21. The nursing note dated [DATE] indicated, . patient continues to climb out of bed, refusing to listen to being redirected. Patient appears to be agitated and saying he wants to go home and will go home . The nursing note dated [DATE], .at 2:35 a.m. the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . The Fall program CP indicated, . Fall program . blue bracelet, blue fall intervention sign above the head of bed, blue name sign by the door, Non-skid footwear, low bed . The care plan was created until five days after Resident 1 ' s fall on [DATE]. The intervention for nonskid footwear and low bed was initiated 8 days after Resident 1 ' s fall on [DATE], when the physician order was documented. The DON stated Resident 1 ' s fall risk score was at 21 on admission, indicating Resident 1 was a high risk for falls. The DON stated Resident 1 had an unwitnessed fall [DATE], was sent to the acute care hospital and diagnosed with a dislocated left-hand pinky. The DON stated there was no change of condition assessment completed, no post fall assessment or skin assessment and there were no neurological checks initiated by the nurse on shift the day of the fall on [DATE]. The DON stated it was the facility process for all documentation to be completed and to properly assess Resident 1 for possible injury. The DON stated, as a result, she was not made aware of Resident 1 ' s fall with injury until [DATE], 4 days later. The DON stated that the fall program which included, a blue bracelet, blue sign above Resident 1 ' s bed, blue name band at the door and low bed, was initiated on [DATE] for Resident 1. The DON stated the fall program should have been initiated upon admission but, was not initiated until after the fall on [DATE] due to DON not being aware Resident 1 had a history of falls. The DON stated Resident 1 would exhibit behaviors manifested by attempting to self-transfer, non-compliant with personal care and non-compliant with using the call light for assistance when his spouse would leave the facility. During a concurrent interview and record review on [DATE] at 12:47 p.m., with the DON, Resident 1 ' s Change of Condition (COC) assessment dated [DATE] and Nursing Note dated [DATE], were reviewed. The COC indicated Resident 1 had an unwitnessed fall on [DATE] with injury. The nursing note indicated, . Resident had unwitnessed fall . resident has left side head injury. Pressure applied to the injury. Medical doctor (MD) notified and received order to send to hospital . The DON stated Resident 1 was found lying on the floor in his room with a left side abrasion to the head. The DON stated she was not aware of the details of the fall as they were not documented and did not know if bed was in a low position at the time of Resident 1 ' s fall on [DATE]. The DON stated there were no floor mats and there was no monitoring protocol put in place for Resident 1. The DON stated Resident 1 ' s intervention was to initiate the fall program to help staff identify Resident 1 as a fall risk. The DON stated she was aware Resident 1 was attempting to walk without assistance but did not identify a pattern of behaviors until after Resident 1 ' s fall on [DATE]. During a phone interview on [DATE] at 2:15 p.m. with LVN 3, LVN 3 stated Resident 1 had an unwitnessed fall on [DATE] and was transferred to the acute care hospital. LVN 3 stated Resident 1 was exhibiting behaviors that included attempts to self-transfer. LVN 3 stated Resident 1 was a high risk for falls and was taken to the nurse ' s station for a one-on-one monitoring. LVN 3 stated the one-on-one monitoring was an intervention that was implemented for that night shift while behaviors were present. LVN 3 stated Resident 1 requested to go back to bed and was taken by CNA 3 to his room. LVN 3 stated Resident 1 was assisted back to bed and was left in his room without monitoring. LVN 3 stated that approximately 30 minutes later, CNA 3 reported Resident 1 had an unwitnessed fall and was found lying on the floor. LVN 3 stated when Resident 1 was experiencing behaviors manifested by attempts to self-transfer, confusion, or restlessness, it was important to monitor Resident 1 for safety and not left alone while the behaviors were present. LVN 3 stated when a resident was admitted to the facility with a history of falls, the fall program should have been initiated immediately for prevention of falls. Resident 1 ' s fall program was initiated on [DATE], eight days after admission to the facility. During a telephone interview on [DATE] at 2:26 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 had an unwitnessed fall on [DATE]. RN 1 stated Resident 1 had behaviors manifested by attempting to self-transfer from the bed to wheelchair. RN 1 stated Resident 1 required frequent re-orientation after Resident 1 ' s spouse would leave the facility. RN 1 stated Resident 1 was at a high risk for falls and was concerned that Resident 1 ' s room was too far from the nurse ' s station. RN 1 stated Resident 1 had episodes of being confused, was oriented to self and situation at times. RN 1 stated that when a resident is admitted to the facility with a history of falls, the fall program should be initiated immediately for resident safety. Resident 1 ' s fall program was initiated on [DATE], eight days after admission to the facility. During a review of Resident 1 ' s Emergency Department Note dated [DATE], the note indicated, . unwitnessed, patient found on ground (in facility), positive for head strike with laceration to left head, patient reports loss of consciousness . Glasgow Coma Scale (GCS- 13 a clinical scale used to measure a person ' s level of consciousness after a brain injury. Score levels 3-8 are sever traumatic brain injury [TBI], 9-12 moderate TBI, and 13-25 mild TBI) 14 per emergency medical systems patient is at baseline . 3 centimeter (unit of measure) laceration to posterior (back) scalp . Computed tomography scan (CT- diagnostic imaging procedure produces images of the inside of the body) impression: Right posterior parafalcine subdural hematoma measures up to 5 millimeters (unit of measure) . will be admitted to the trauma service for ground level fall causing intracranial bleed . During a record review of Resident 1 ' s critical Care Note, dated [DATE], the note indicated, . Patient is seen and examined at bedside. Alert and following commands. Appear slightly confused with garbled speech. Close to baseline per family at bedside. Does not recall falling . considering patient has had multiple falls over the past few weeks as well as his underlying Parkinson ' s and other comorbidities (the condition of having two or more diseases at the same time), I have recommended a palliative care evaluation . During a review of Resident 1 ' s Palliative Care Consultation Note, dated [DATE], the note indicated, . met with [Family] . at baseline they feel he (Resident 1) experiences hallucinations at times. [Family member] expressed concerns about patient having dementia . he has had several falls .that other issues such as his impulsiveness and falling might be his undoing . During a review of Resident 1 ' s hospital Trauma Surgery Discharge Summary, dated [DATE], the summary indicated, . Closed head injury, Palliative care patient, Syncope (fainting), Scalp laceration, Subdural hematoma, Ground-level fall, traumatic brain injury (TBI) . Injuries were found to be non-operative. He remained neurologically intact to baseline until [DATE] when he became unresponsive . On [DATE], patient reported dyspnea (difficulty breathing) to the CNA at bedside after mobilizing with physical therapy (PT). CNA called staff and rapid response. Patient was unresponsive, pale, cyanotic(blue) with agonal (not getting enough oxygen and gasping for air) breathing in pulseless electrical activity (PEA- condition when there is no pulse, no heartbeat, and no breathing). During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 9/2023, the P&P indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . once a review is completed resident may be placed on the fall program. The individuals that have two or more falls in 90 days or fall with injury will be automatically placed on the fall program . the facility can use the following interventions but not limited to these interventions for the resident. falling matt, 1:1, bed in lowest position, moving resident closer to the nurse ' s station, call lights within reach . or any other interventions that are resident centered . During a review of the facility ' s P&P titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, . Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents .the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in environment. The type of frequency of resident supervision may vary among residents and over time for the same resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision and services for the prevention of accidents for two of five sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 were both admitted with diagnoses that included dysphagia (difficulty swallowing or chewing) and were not evaluated or treated in accordance with professional standards of practice and the comprehensive care plan. Speech Therapy was not consulted, swallow evaluations (to determine the presence and severity of dysphagia as well as to determine the need for further testing) not conducted, meals were not supervised, modified meals to prevent the risk of choking and risk of aspiration (sucking food into the airway) were not served. These failures resulted in the risk of choking and aspiration for both Residents 1 and 2; and for Resident 1 could have contributed to the event on 4/11/24 where Resident 2 was found pulseless while eating and coroner's preliminary report indicated cause of death as asphyxia (condition caused by an injury or obstruction of the airway passages like choking) due to aspiration from food. Findings: 1. During a review of Resident 1's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis, Dysphagia. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 3/8/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 2 out of 15 (0 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 15) cognitively intact) which indicated Resident 1 was cognitively impaired. During a review of Resident 1's Nursing Situation, Background, Assessment and Recommendation (SBAR) dated 4/11/24, the SBAR indicated, . Resident found unresponsive in his wheelchair (w/c) . Resident had food in his mouth and airway had to be cleared out . During a review of Resident 1's Meal Tray Ticket (MTT), dated 4/11/24, the MTT indicated, . Lunch . consistent carbohydrate diet (CCD) Dysphagia advanced . Italian sausage . brown gravy . parmesan noodles . sauteed spinach with garlic . dinner roll/bread . sliced pears . 8 oz skim milk . During a review of Resident 1's nutritional Care plan (CP) dated 2/20/23, the CP indicated, . monitor/document/report when needed (PRN) any s/sx (sign/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals . During an interview on 4/17/24 at 11:51 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she responded to Resident 1's room on 4/11/24 due to a call for help from CNA 1. LVN 1 stated that upon entering Resident 1's room, Resident 1 was observed sitting up in his wheelchair, head tilted backward, arms resting on arm rest, facing his bed with back turned to roommate and bedside table was positioned to the front of Resident 1. LVN 1 stated Resident 1's meal tray was on top of the bedside table, there was no food on the plate, and it appeared Resident 1 had consumed the entire lunch meal. LVN 1 stated Resident 1's head was straightened up and carotid pulse (pulse felt on the front of the neck below the angle of the jaw) was checked and LVN 1 determined Resident 1 did not have a pulse. LVN 1 stated CPR was initiated. During an interview on 4/17/24 at 12:18 p.m. with the Assistant Director of Nursing (ADON), the ADON stated on 4/11/24 there was a code (life threatening emergency) called for Resident 1. The ADON stated upon entering Resident 1's room LVN 2 was observed performing chest compressions (also called cardiopulmonary resuscitation [CPR] action used to push down hard and fast in a specific way on the person's chest) on Resident 1 who was lying on his back on the floor. The ADON stated the artificial manual breathing unit bag (ambu bag a device used to provide respiratory support) was placed over Resident 1's nose and mouth. The ADON stated when the ambu bag was compressed to assist with respirations it was noted, the ambu bag was not delivering oxygen appropriately as Resident 1's chest, because Resident 1's chest did not rise. The ADON stated Resident 1's head was repositioned and Resident 1's tongue was observed hanging to the side of his mouth. The ADON stated she inserted two fingers into Resident 1's mouth to feel for any residual food and felt tongue was swollen. The ADON stated there was no food felt in Resident 1's mouth but observed the DON scooping Resident 1's bilateral cheeks. The ADON stated she observed the Director of Nursing (DON) scoop out pocketed food from Resident 1's cheek which was size of a quarter, the food appeared to be spinach and pasta. The ADON stated the suction machine was used to remove remaining food particles from Resident 1's mouth. The ADON stated once the food was removed from Resident 1's mouth, the ambu bag was repositioned and Resident 1's chest began to rise when oxygen was delivered. The ADON stated Resident 1 required set up help for meals and did not have previous concerns with meal consumption. During an interview on 4/17/24 at 12:50 p.m. with the Registered Nurse Supervisor (RNS), the RNS stated he was called to Resident 1's room for a Code. The RNS stated that upon entering the room he observed the DON using the ambu bag and LVN 2 delivering compressions to Resident 1. The RNS stated when the ambu bag was used it was noted not delivering oxygen appropriately as Resident 1's chest was not rising. The RNS stated the DON scooped Resident 1's bilateral cheek and removed approximately 30 mL's (unit of measure) of food from Resident 1's mouth. The RNS stated the suction machine was used to remove remaining food particles from Resident 1's mouth. The RNS stated the food appeared chewed and looked like spinach mixed with an unknown white substance. The RNS stated there were no known food or drug allergies for Resident 1. The RNS stated, when the food was removed from Resident 1's mouth, the ambu bag was repositioned and oxygen was delivered effectively. During an interview on 4/17/24 at 1:11 p.m. with the DON, the DON stated she was called to Resident 1's room for a code. The DON stated when she entered Resident 1's room, LVN 2 was observed administering chest compressions to Resident 1 who was observed lying on the floor on his back. The DON stated Resident 1's skin appeared pale, he was fully dressed, eyes were open, and body was flaccid. The DON stated she assessed Resident 1's carotid pulse and concluded there was no pulse. The DON stated she was in charge of the ambu bag during cardiopulmonary resuscitation and noted there was a leak in the ambu bag seal when Resident 1's chest did not rise. The DON stated she removed the ambu bag and proceeded to scoop Resident 1's bilateral cheek for food. The DON stated there was food removed from the left cheek that appeared to have been spinach and there was food removed from the right cheek that appeared as ground meat. The DON stated she was unsure how much food was removed from Resident 1's mouth but that it was a small amount. The DON stated Resident 1 had an unusually heavy tongue that required for it to be pulled out of Resident 1's mouth to suction the back of the throat for remaining food particles. The DON stated once Resident 1's mouth was cleared of food, the ambu bag was repositioned and effectively delivered oxygen when Resident 1's chest was observed to rise. The DON stated Resident 1 required set up help only for meals and had a diagnosis of dysphagia without prior complications. During an interview on 4/17/24 at 1:39 p.m. with the Regional Director of Rehab (RDR), the RDR stated Resident 1 was not evaluated or treated in the facility since admission by the Speech Therapy department. The RDR stated there were no speech therapy notes in Resident 1's electronic medical record (EMR). During a concurrent interview and record review on 4/17/24 at 1:43 pm with the DON, Resident 1's EMR and nutritional care plan dated 2/20/23, were reviewed. The EMR indicated Resident 1 was not evaluated or treated by a speech therapist (ST) since admission to the facility on 2/17/23. The CP indicated, . monitor/document/report when needed (PRN) any s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals . The DON stated the facility staff was not monitoring Resident 1 specifically for pocketed food or choking. The DON stated the expectation was for a monitoring order to have been put in place to monitor Resident 1 during and after meals as there was a potential for pocketing food to become a choking hazard. During an interview on 4/17/24 at 1:52 pm with CNA 1, CNA 1 stated she was assigned to care for Resident 1 on 4/11/24. CNA 1 stated Resident 1 was served his lunch tray in his room while he sat in his wheelchair with bedside table positioned in front of him and then she exited the room. CNA 1 stated when she entered Resident 1's room to retrieve the lunch tray, Resident 1 was observed sitting in wheelchair with head tilted back, eyes open but wasn't responding to verbal stimuli. CNA 1 stated she was not aware that Resident 1 had a history of pocketing or choking on food. CNA 1 stated it was important to monitor Resident 1 as there was a potential for choking during meals. During a review of Resident 1's dietary profile dated 3/16/23, the dietary profile indicated, . Resident does not speak English, so his Family Member (FM) was called for preferencing interview. She said her father has a hard time chewing some meals due to dental issues. Will tell speech therapist about it . During a concurrent interview and record review on 4/18/24 at 9:29 a.m. with the speech therapist (ST), Resident 1's EMR and nutritional care plan dated 2/20/23, were reviewed. The EMR indicated Resident 1 was not evaluated or treated by a ST since admission to the facility on 2/17/23. The CP indicated, . monitor/document/report when needed (PRN) any s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals . The ST stated that based on Resident 1's history, the facility should have downgraded Resident 1's diet to a puree texture and should have referred to ST services to ensure resident was given the appropriate diet. The ST stated that based on Resident 1's history, diagnosis and care plan it was her professional opinion that Resident 1 should have been referred, evaluated and treated as indicated by a ST. During a concurrent interview and record review on 4/18/24 at 10:18 a.m. with the facility's registered dietitian (RD), Resident 1's diet order dated, 2/19/23, and dietary profile dated 3/16/23, were reviewed. The diet order indicated, Consistent Carb Diet dysphagia advanced texture thin liquids. The dietary profile indicated, . Resident does not speak English, so his daughter was called for preferencing interview. She said her father has a hard time chewing some meals due to dental issues. Will tell speech therapist about it . The RD stated Resident 1 was admitted to the facility with a diet order for Dysphagia advanced texture and continued without a diet change until Resident's death on 4/11/24. The RD stated that a dysphagia advanced texture consisted of finely chopped foods, dinner rolls and pasta and should have been soft and did not require chopping. The RD stated the dietary manager (DM) in the facility at the time of the documented dietary profile was no longer an employee of the facility. The RD stated the process was for the dietary manager to attend all resident's interdisciplinary team (IDT team of healthcare professionals who work together toward the goals of their clients) meetings and report any findings. The RD stated the DM should have notified the ST and the IDT team of the family's concern at the time of the dietary profile to evaluate Resident 1's diet. During a telephone interview on 4/24/24 at 3:10 p.m. with the coroner's office sheriff (COS), the COS stated, Resident 1's preliminary report indicated cause of death was asphyxia due to Aspiration of food. During a telephone interview on 4/24/24 at 2:50 pm with the family member (FM) 1, the FM 1 stated Resident 1 had a history of dysphagia that presented by difficulty swallowing foods. FM 1 stated Resident 1 had episodes of pocketing food during meals and required supervision and redirection during meals. FM 1 stated the facility staff was informed that Resident 1 was pocketing food and FM1 requested staff follow up with Resident 1 during meals. During a telephone interview on 4/24/24 at 3:38 p.m. with LVN 3, LVN 3 stated Resident 1 had a diagnosis of dysphagia since admission. LVN 3stated dysphagia was interpreted as trouble swallowing food. LVN 3 stated the facility process was for the admitting nurse to look at Resident's history and determine which diet order was in place and notify the physician. LVN 3 stated Resident 1 was administered crushed medications in applesauce during medication administration because Resident 1 had a hard time swallowing. LVN 3 stated Resident 1 did not have a physician order in place to crush medications. LVN 3 stated the facility process was for the facility nurses to notify MD and speech therapy if Resident 1 was having trouble swallowing and this was not done for Resident 1 . During a review of Resident 1's Emergency Medical Services (EMS) Patient Care Report, dated 4/11/2024. The EMS report indicated, . Oropharyngeal Airway (OPA device used to maintain an open airway by assisting in moving the tongue or other possible obstructions and improving the airway, placed, but rejected by patient due to intact gag reflex. Initial video laryngoscopy (procedure in which a fiberoptic camera is used to visualize the upper airway for intubation) utilized for use in clearing airway, where bits of noodle and greens were removed. 2. During a review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Dysphagia. During a review of Resident 2's Minimum Data Set (MDS a resident assessment tool used to identify cognitive and physical functional level assessment) dated 3/21/24, the MDS indicated Resident 2's BIMS score was 13 out of 15 which indicated Resident 2 was cognitively intact. During a review of Resident 2's Dietary Order, dated 12/16/2020, the Diet order indicated, . Regular diet, regular texture, thin consistency . During a review of Resident 2's Dental Consult, dated 11/13/23, the dental consult indicated, . Resident strongly refusing extractions today, stated why pull them if they don't hurt me, patient does not want extractions . During a concurrent interview and record review on 4/24/24 at 1:20 p.m. with the DON, Residents 2's EMR was reviewed. The EMR indicated Resident 2 was not evaluated or treated by ST since admission to the facility. The DON stated that upon review of the EMR, Resident 2 had no documented history of speech therapy services. During a concurrent observation and interview on 4/26/24 at 12:05 p.m. with Resident 2 in Resident 2's room, Resident 2 was observed lying in bed. Resident 2 stated the facility speech therapist, as far as she was aware, had not evaluated her. 2 stated she was not having issues chewing or swallowing food at the time of the interview but was experiencing facial nerve pain. Resident 2 stated the facial nerve pain was located on her left side of the face. Resident 2 stated that there were times when she had to put her head up to swallow food due to the nerve pain. Resident 2 was observed lifting head backward to show position for swallowing. During an interview on 4/26/24 at 12:33 p.m. with the physical therapy assistant (PTA), the PTA stated after review of Resident 2's physical therapy documentation, Resident 2 had not been evaluated or treated by speech therapy since admission. During a concurrent interview and record review on 4/26/24 at 12:55 p.m. with the social services assistant (SSA), Resident 2's dental consult, dated 11/13/24 was reviewed. The dental consult indicated, . Resident strongly refusing extractions today, stated why pull them if they don't hurt me, patient does not want extractions . The SSA stated Resident 2 was last seen by the dentist on 11/13/23 and had refused any further treatment. The SSA stated Resident 2 had a lot of dental issues that needed to be addressed including multiple tooth extractions. During a concurrent telephone interview and record review on 5/6/24 at 9:22 a.m. with the facility ST, Resident 2's EMR, diet order dated 12/16/2020 and dental consult dated 11/13/2023 were reviewed. The EMR indicated Resident 2 had not been referred, evaluated, or treated by a ST since admission to the facility. The Diet order indicated, . Regular diet, regular texture, thin consistency . The ST stated, it was her professional opinion that based on Resident 2's diagnosis of dysphagia, resident reports of left sided facial pain, inability to swallow and documented dental issues, Resident 2 should have been referred to ST for an evaluation, MD notified of concern and diet changed. During a telephone interview on 4/24/24 at 4:24 p.m. with Registered Nurse Manager (RNM), the RNM stated the facility process for residents with dysphagia was for the admitting nurse to notify the physician and refer to speech therapy for evaluation. The RNM stated all residents with dysphagia should have been monitored and referred to speech therapy services for an evaluation. The RNM stated if Resident 2 had a history of difficulty swallowing, it was expected that Resident 2 be referred to speech therapy. During a telephone interview on 4/24/24 at 4:26 p.m. with the DON, the DON stated it was the facility process when a resident is admitted with a diagnosis of dysphagia, to request a speech therapy evaluation. The DON stated it was the expectation for the admitting nurse to clarify with physician and follow the diet orders sent from the hospital upon admission. The DON stated it was the expectation that nursing staff monitor the resident for any changes in eating habits. The DON stated it was not an acceptable practice to not monitor a resident with a diagnosis of dysphagia including Resident 1 and Resident 2. During a telephone interview on 4/24/24 at 4:28 p.m. with the facility administrator (ADM), the ADM stated it was the expectation that the admitting nurse notify MD and obtain an order for speech therapy services for residents with dysphagia upon admission. The ADM stated if the facility staff identified difficulty with eating or swallowing it was the expectation that the charge nurse evaluate and asses the resident and refer to speech therapy for evaluation. During a review of the facility's policy and procedure (P&P) titled, Speech Therapy, dated 5/2013. The P&P indicated, . The purpose of this procedure is to identify, assess and treat speech and language problems including swallowing disorders . Speech therapists treat . Dysphagia difficulty in chewing or swallowing . the speech therapists work to provide a comprehensive evaluation and treatment plan for residents . the speech therapists complete an evaluation of the following speech and language skills . ability to swallow . During a review of the facility's policy and procedure (P&P) titled, Dysphagia, dated 9/2017, the P&P indicated, . the staff and the physician will identify individuals with a history of swallowing difficulties or related diagnosis such as dysphagia . based on the information collected and correlated by various disciplines, the staff and practitioner, in conjunction with the SLP (speech language pathologist), will define the situation carefully . and whether the situation needs additional evaluation and clarification . if a swallowing problem is identified or suspected, a healthcare practitioner, in conjunction with nursing and SLP, will identify and document pertinent information, including the resident's level of consciousness, ability to swallow 3 ounces of water without drooling, coughing, or choking . previous and recent history of swallowing capability and difficulty . it is important to clarify the symptoms and the history in detail in order to help identify causes, since symptoms related to chewing or swallowing may have modifiable causes .

**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 ensure the resident environment was accident-free for four of ten sampled residents (Residents 2, 3, 7, and 8) when Licensed Nurses failed to follow facility policy and procedures and professional standards in developing and implementing resident-specific and comprehensive care plan interventions meant to prevent falls for Residents 2, 3, 7 and 8. These failures resulted in avoidable falls for Residents 2, 3, 7 and 8. Each resident suffered an injury requiring transport, assessment, and healthcare services at a General Acute Care Hospital (GACH). Resident 2 experienced an avoidable fall on 2/25/2023 and suffered a worsening to an already existing left proximal femur fracture (broken thigh bone), decreased ability to function, decreased mobility, disruption of healing, and increased pain. Resident 3 experienced two avoidable falls on 3/20/2023 and was diagnosed with a Traumatic Brain Injury (TBI- a sudden injury that causes damage to the brain), decreased ability to function, decreased mobility and pain. Resident 4 experienced an avoidable fall on 4/28/2023 and was diagnosed with a ground level fall .traumatic hematoma [a collection of blood outside of blood vessel commonly caused by an injury] to the left head, decreased ability to function, decreased mobility. Resident 7 experienced an avoidable fall on 3/17/2023 and was diagnosed with a right closed femur fracture, decreased ability to function, decreased mobility pain. Resident 8 experienced an avoidable fall on 2/4/2023 and was diagnosed with a right occipital bone fracture, (broken skull bone) and laceration (cut). Findings: 1. During a review of Resident 2's Nursing SBAR [Situation-Background-Assessment-Recommendation- a standardized way for members of the health care team to report about a patient's condition.] dated 2/25/2023 indicated Resident 2 was transferred to the GACH for a complaint of left knee pain after an unwitnessed fall from bed, in his room, at 10:00 p.m. During a review of Resident 2's Face Sheet (FS- a document containing resident profile information) dated 4/13/2023, the FS indicated, Resident 2 is a [AGE] year old initially admitted to the facility on [DATE] for rehabilitation with diagnoses which included .Major Depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) . Type 2 Diabetes Mellitus (Diabetes) with hyperglycemia (high blood sugar), .hypertension (high blood pressure) . Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) .with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety .Fall .need for assistance with personal care . Fracture of left femur (broken thigh bone) .Muscle weakness .difficulty walking . During a review of Resident 2's Avalon Fall Risk Evaluation (AFRE), dated 2/17/2023 (before the fall with injury on 2/25/2023), the AFRE indicated, .Score: 16 (which indicated Resident 2 was a medium risk for falls) . the AFRE .dated 3/3/2023 (after the fall with injury on 2/25/2023) indicated, .Score: 14 (which indicated Resident 2 was a medium risk for falls) . During a concurrent interview and record review, on 4/14/2023, at 9:00 a.m., with MDSC 1, Resident 2's Care Plan was reviewed. Resident 2's Care Plan indicated Focus [Resident 2] has had an actual fall .Date Initiated: 3/9/2023 .Goal [Resident 2} will resume usual activities without further incident through the review date .Interventions .frequent room check for pt safety .keep bed locked and in low position .fall mat in place . The MDSC 1 stated Resident 2's care plan did not include interventions specific enough to minimize the potential for accidents specific to Resident 2's admission diagnoses. The MDSC 1 stated that examples of interventions that could have been implemented instead of frequent room check for pt safety, licensed nurses could have planned scheduled rounding by CNA every 30 minutes and nurse every 60 minutes, keeping personal items within reach, and answering call light within a specific timeframe (under 5 minutes) and to remove clutter, keep belongings at bedside within resident reach. Ensure that call lights are answered right away and to stay alert to any unexpected noises. The MDSC 1 stated these interventions would help keep the resident safe because the resident forgets has Dementia and Resident 2 does not always call for help with ADL's. The MDSC 1 stated Resident 2 does not always remember not to raise the bed height when he has access to the remote control, staff should anticipate that the bed height could be a problem and during rounding should inspect the current height of the bed, lower the bed as needed and keep the remote control out of sight to prevent the resident from accidentally raising the bed height. The MDSC 1 stated that planning for fall mat should include the location where (right or left) the mat is to be placed. The MSDC 1 stated that Resident 2's Care Plan did not include a pain management focus. The MDSC 1 began to modify the Care Plan as the interview was underway to include the specifics he mentioned. MDSC 1 stated that as the facility MDSC and RN, he has the responsibility to update and modify resident Care Plans as appropriate. The MDSC 1 stated the purpose of a care plan is to meet the specific needs of each resident if there isn't a good plan the result could be harm, like in this case Resident 2 suffered a re-injury and had to have a second operation on his left leg. The MDSC 1 stated as a Registered Nurse (RN) it is his expectation that licensed nurses update the care plan anytime the resident has a new or change in condition. During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., of Resident 2's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive and physical functional status assessment) Section C dated 2/23/2023, with the MDS Coordinator (MDSC) 1, the MDSC 1 stated Resident 2's Brief Interview for Mental Status (BIMS- assessment of cognitive [pertaining to reason, memory and judgement] status) was 10 of 15 points (indicating moderate cognitive impairment in decision making during Activities of Daily Living [ADL's- bathing, toileting, transferring] and required cues and supervision). Resident 2's MDS Section G, dated 2/23/2023 indicated Resident 2 required .extensive assistance of two, plus staff members to transfer from one surface to another . During a concurrent observation and interview on 4/14/2023, at 10:46 a.m., with Resident 2, in Resident 2's room, Resident 2's environment was observed to have a privacy curtain was drawn around his bed in the semi-private room. Resident 2 was lying in bed, eyes open, alert, relaxed, television was on and bedside table approximately two feet away from resident's reach. Resident 2 stated that sometimes staff leave his bedside table too far away where he is unable to reach his glasses and something to drink. Resident 2 was observed to not have soft floor mats on the floor at his bedside. Resident 2 was not wearing a fall risk armband and there was no fall risk sign present to alert staff to Resident 2's fall risk. Resident 2 stated that he did not recall what he was doing at the time of the fall, or exactly when the fall happened. Resident 2 says he remembered being told he had a broken foot. Resident 2 stated that he went to the hospital and had to have his foot operated again after he slipped and fell. Resident 2's call bell was located at the head of the bed, near Resident 2's right shoulder. Resident 2 stated the call bell wasn't working, it was missing the red button. Resident 2 stated when the call bell is at his right side, he can't press it because his right arm doesn't work. Resident 2 pointed, with his left hand, to his right arm which was lying on top of Resident 2's lap to demonstrate the flaccid (a body part hanging loosely or limp) condition of his right arm. During a concurrent observation and interview on 4/14/2023, at 10:53 a.m., with Resident 2 and Certified Nursing Assistant (CNA) 1, in Resident 2's room, CNA 1 responded to a request for assistance. It was brought to CNA's attention that the call light was on Resident 2's right side. CNA 1 placed the call button in Resident 2's left hand. Resident 2 pressed the call button; the call light did not alarm. Resident 2 stated that when the call light does work, staff do not respond right away. Resident 2 stated he has waited over 30-minutes for help. CNA 1 stated she was not aware that the call light wasn't working. CNA 1 stated that she would try to fix the call bell by either taking a working call bell from another room or by entering a report for maintenance to fix it if she could not fix the problem. CNA 1 stated she did not understand why the privacy curtain was closed. CNA 1 stated that Resident 2 sometimes called out or waved to staff if he needed help. CNA 1 stated that with the privacy curtain is drawn, when care wasn't actively being provided, Resident 2 did not have a way to alert staff he needed help and staff could not see resident from the hallway. During a concurrent interview and record review on 4/17/2023 at 4:20 p.m., with MDSC 1 in the facility conference room, Resident 2's Inter-Disciplinary Team Meeting (IDT- [interdisciplinary team-approach to healthcare that integrates multiple disciplines through collaboration]) note, dated 4/17/2023 was reviewed. The MDSC 1 stated Resident 2 was hospitalized from [DATE] to 3/3/2023 (six days) with no new falls reported since his return from the GACH. The MDSC 1 stated that the IDT Note was not entered into the system directly after the IDT met to review the fall event. The MDSC 1 stated it was entered as a late entry on 4/17/2023.; The meeting was held on 3/6/2023 at 11:00 a.m. The IDT Note indicated .IDT met to discuss recent unwitnessed fall on 2/25/23 which caused an injury to a pre-existing left femur fx [fracture]. According to charge nurse assessment, LLE [left lower extremity] was swollen and pt [patient] complained of 10 out 10 pain and requested to be sent to acute [GACH]. Pt returned to facility on 3/3/23 after hardware revision on the L [left] femur fx, with current weight bearing order of touch toe (no weight bearing, only toe touches floor). Care plan (direction on the type of nursing care the individual may need) updated regarding fall precautions. IDT Present: Administrator (ADM), Social Services Director (SSD), Physical Therapist (PT) Occupational Therapist (OT), Restorative Nursing Assistant (RNA) Director of Staff Development (DSD), Infection Prevention/Unit Manager (IP/UM), MDSC 1 . The MDSC 1 stated Resident 2 experienced a decline in mobility and increased pain and suffering due to the fall and re-injury of the left lower extremity (limb). During a review of Resident 2's Order Summary Report, (OSR) dated 4/13/2023, the OSR indicated, . [Generic Name] opioid (a class of drug used to reduce moderate to severe pain) pain medication 5 mg .give 1 tablet by mouth every 4 hours as needed for pain . During a review of the Medication Administration Record (MAR) dated 3/1/2023 indicated, on 3/22/2023 Resident 2's pain level was a 10 (physician's order dated 2/17/2023 indicated, monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible .) and Ibuprofen (pain reliever) 400 milligrams (mg- a unit of measurement) was administered, 3/24/2023. Resident 2 reported a pain level of 6 and Ibuprofen 400 milligrams was administered, 3/28/2023 Resident 2 reported a pain level of 6 and Ibuprofen 400 milligrams was administered, 3/29/2023 Resident 2 reported a pain level of 6 and Ibuprofen 400 milligrams was administered. During an observation and interview on 5/25/2023 at 1:20 p.m., on the unit, with Resident 2, in Resident 2's room, Resident 2 stated feels so-so, pain medication given but doesn't seem to help (Ibuprofen). Resident 2 was wearing gray nonslip socks, no fall mat on either side of bed present. Resident 2 stated that call light doesn't work will call for assistance and the light will ring and ring and no one answers. Resident pressed call light and a Call Light Attendant (CLA) 1 responded within three minutes. During a review of Resident 2's Emergency Department (ED) Note/History and Physical (H&P) dated 2/25/2023, the ED Note/H&P indicated, .Left thigh pain with associated shortness of breath .reports that he was transferring from his bed to his bathroom when he fell. No head strike or loss of consciousness reported .Final Diagnosis .closed fracture of proximal end of left femur (broken thigh bone) .ED MD consulted Orthopedic Surgeon. The ED Note/H&P indicated .spoke to [Orthopedic Surgeon] who says that [Resident 2] would need to be admitted for a revision . Consult to Orthopedic Surgery .Left femur peri implant fracture .HPI . [Resident 2] is a [AGE] year-old male with left femur peri implant fracture. He was seen and evaluated at [local GACH] sometime in January when [Resident 2] was treated with a short intramedullary nail to the left femur. Apparently, [Resident 2] sustained recurrent injury while in rehabilitation that resulted in a peri implant femur fracture [break(s) around joint replacement prostheses (artificial body part, such as a leg, a heart or a breast implant) are commonly called periprosthetic fractures whereas fractures around plates, rods, or prostheses]. [Resident 2's] fracture began at the distal aspect of the intramedullary nail and has resulted in shortening and mechanical failure of the current implant. During a review of Resident 2's hospital records of Resident 2's [X-Ray] (picture through the body to see bones) Femur Left Final Result (XR [X-ray] femur 2 or more views), dated 2/25/2023, the XR femur indicated, .Reason for exam .Left femur pain status post (after) femur fracture .Finding/Impression .ORIF [Open reduction and internal fixation- a surgical procedure for repairing fractured bone using either plates, screws or a rod to stabilize the bone changes] of the left femur. 2.During a review of Resident 3's Progress Note dated 3/20/2023 at 12:35 a.m., (fall event number one). The Progress Note indicated the Registered Nurse (RN) was called to resident's room approximately 12:30 a.m. on entering room, resident was found lying on the floor on the right side of his bed on his back. Upon assessment [Resident 3] was noted to be bleeding from the back of his head and his left eyebrow where he sustained a laceration no loss of consciousness noted alert with confusion, pressure applied to bleeding laceration, 911 was called and pt [patient] was taken to the Emergency Department (ED) at a [local GACH] . During a review of Resident 3's Progress Note dated 3/20/2023 2:45 a.m. (fall event number two) the Progress Note indicated Pt had an unwitnessed fall at [1:00 a.m.]. Pt was yelling help from his room, call light had just turned on per assigned CNA. [Two] CNAs responded to room, at this time, pt was found lying face down with blood on floor. Pt was lying on floor right hand side of bed, with chair between window and bed staff immediately called out for RN charge nurse to respond to room for further assessment. [Two] X2 nurses responded and found patient on his back, with large amounts of blood on floor and surrounding patient. Pt had a laceration to left elbow, under L (left) eye L eyebrow and back of head. UTD [Unable to Determine] size of lacerations, bed was in lowest position, pt was unable to state how he fell or what caused him to fall. [Ambulance] was called immediately, arrived within just a couple of minutes, pt was refusing to allow staff to apply pressure drsg [dressing] to wound laceration, continuously rips drsg off. Pt repeating I'm ok pt awake, responsive verbally with forgetfulness. Pt was lifted by four CNA's and the paramedics onto gurney pt to be assessed at [GACH] During a review on 4/13/2023 of Resident 3's Face Sheet (FS) dated 4/13/2023, the FS indicated, Resident 3 is a [AGE] year-old and was initially admitted to the facility on [DATE], with a history of falls .Polycythemia Vera (a disease in which there are too many red blood cells in the bone marrow and blood, causing the blood to thicken) .muscle weakness .Wernicke's Encephalopathy (a neurological disorder caused by thiamine (a nutrient in the vitamin B complex that the body needs in small amounts to function and stay healthy) deficiency, typically from chronic alcoholism or persistent vomiting, and marked by mental confusion, abnormal eye movements, and unsteady gait) .cognitive communication deficit (difficulty with thinking and how someone uses language) .Type 2 Diabetes Mellitus (diabetes- a disease of too much sugar in the blood) .difficulty walking . Resident 3 was re-admitted to the facility on [DATE], (after a hospital stay from 3/20/2023 to 3/27/2023 or seven days), with diagnoses which included .Intracranial Injury (injury to the skull following a head strike) with Loss of Consciousness (fainting) .Traumatic Subdural hemorrhage (bleeding in the area between the brain and the skull) with loss of consciousness .fall .Fracture .cervical vertebra [bone] .base of skull .orbit, . Laceration (cut) of head . During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with MDSC 1 of Resident 3's Risk History report (history of reported events (such as falls, injury or behavioral)) dated 4/14/2023, the MDSC 1 stated Resident 3 had a long history of both witnessed and unwitnessed falls. MDSC 1 stated the last reported fall (unwitnessed) was on 12/2/2022. The Risk History report indicated Resident 3 had an unwitnessed fall on 12/2/2022, 1/15/2022, 12/6/2021, 6/15/2021, 6/7/2021, 1/30/2021, 1/29/2021, 1/28/2021, 1/27/2021, 9/2/2017, 4/21/2017. The report indicated Resident 3 had a witnessed fall on 10/30/2021- with head injury, 1/27/2021, 11/23/2019- with head injury, 9/25/2017- with head injury. During a concurrent interview and record review on 4/14/2023 at 09:15 a.m., with the MDSC 1, of Resident 3's MDS dated [DATE], the MDSC 1 stated Resident 3's MDS Section C- BIMS was 6 of 15 points (indicating severe cognitive impairment in decision making .). The MDS Section G indicated Resident 3 needed one-person physical assist for all ADL's . During an observation on 4/14/2023, at 10:20 a.m., in Resident 3's room, Resident 3 was lying in bed, on his back; the bed was in low position (close to the floor). Resident 3 had eyes open, responded to name, nodded, and smiled, but did not speak. Resident 3 held a brown ball, about the size of a golf ball, in his right hand. This ball was presumed to be feces as there was a strong mal odor in the room and brown substance smeared on Resident 3's hands, clothing, and sheets. Facility staff was immediately alerted to this observation. During a review of Resident 3's AFRE, dated 12/2/2022 (before the fall with injury on 3/20/2023), the AFRE indicated, .Score: 8 (which indicated Resident 2 was a low risk for falls) .resident had an unwitnessed fall while attempting to transfer self to the restroom without assistance. Resident was in wheelchair and did not lock the breaks when transferring resulting in a head injury to the right side of head, x-ray has been ordered. Resident also has skin tear on the right elbow. Resident also has complained of pain to the left knee no skin tear noted . During a review of Resident 3's AFRE .dated 3/27/2023 (after the fall with injury on 3/20/2023), indicated, a .Score: 15 (which indicated Resident 2 was a moderate to high risk for falls) . During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with the MDSC 1 of Resident 3's Care Plan (CP), dated 3/27/2023, the CP indicated, .Resident had an unwitnessed fall with injury 3/20/2023 .Date initiated: 3/20/2023 .Goal [Resident 3] will have no further complications r/t [related to] fall until next review date . Date Initiated: 3/20/2023 .Target Date: 4/11/2023 .Interventions .frequent room check for safety . prompt response to call light for assistance . The MDSC 1 stated the problem with these interventions was they were not specific enough. The MDSC 1 stated that as written, the current care plan interventions indicating frequent, and prompt left the timing open to individual interpretation versus clear instruction for how often the staff should be checking for safety. The MDSC 1 stated that what frequent or prompt means to one person may not be the same to another. The MDSC 1 stated that Resident 3's history and risk of falls in the facility both witnessed and unwitnessed, was known to licensed nurses. The MDSC 1 stated that Resident 3's CP did not address this history and risk for falls before the 3/20/2023 fall with injury . The MDSC 1 provided an electronic version of Resident 3's CP for Focus .Long Term/Custodial Placement, initiated 1/13/2022, which indicated history of falls with fracture to right hip but did not address fall prevention/safety interventions. The facility was not able to provide any documentation of care planned fall prevention interventions prior to 3/20/2023. During a record review of Resident 3's Progress Notes dated 4/27/2023, the Progress Note indicated the . resident had an unwitnessed fall .4/27/2023 2:00 a.m.attempting to self-transfer to wheelchair .orders . send to ER (Emergency Room) . sustained an unwitnessed fall sustaining multiple skin tears to right arm . per staff there is a change in baseline mentation . 4/27/2023 7:55 a.m.he stated he was trying to get to his wheelchair. During an interview on 5/25/2023 at 11:37 a.m. with CNA 1, CNA 1 stated Resident 3 had two falls on 4/27/23 and was taken to GACH for evaluation. CNA 1 stated Resident 3 was readmitted later that day with a neck brace. CNA 1 stated Resident 3 has been at the facility for approximately six years and has recently declined. CNA 1 stated he was able to walk but now he keeps falling. During a concurrent observation and interview on 5/25/2023 at 11:58 a.m., with Resident 3 in Resident 3's room, Resident 3 was lying on his back in his bed with a brace on his neck. The privacy curtain was pulled around Resident 3 blocking him from view to staff at Nurse's Station and in the hall. Resident 3 appeared to be confused and when asked if he remembered falling, he pointed to the floor. Resident 3 did not speak or communicate by nodding his head. During an interview and record review on 5/25/2023 at 12:53 p.m., with the MDSC 1 The Fall Check List was reviewed. The Fall Check List indicated; the steps required after each resident falls. Risk Management Entry . Fall Evaluation .: Care Plan with Immediate Fall Intervention . The MDSC 1 stated the facility was not following the facility's Fall P&P or the Care Plan P&P. The MDSC 1 stated there were no new planned interventions put into place for Resident 3 following the falls on 4/27/2023. 3. During a review of Resident 7's Nursing Situation-Background-Assessment-Recommedation (document which provides a framework for communication between members of the health care team about a patient's condition) dated 3/17/2023, indicated, Resident 7 .was seen falling in the bathroom. Patient was toileting and was trying to close the door to the bathroom. Patient c/o [complained of] pain in the hip . this started on: 3/17/2023 [12:10 a.m.] .Patient was sent out to hospital due to the hip pain possible fracture . During a review of Resident 7's General Acute Care Hospital (GACH) Medical Records, the Emergency Department History and Physical (H&P) indicated resident 7's Chief Complaint was due to a fall with resultant hip pain. Resident 7 was admitted to the GACH for right hip fracture and taken to surgery on 3/18/2023 for an .Open Reduction Internal Fixation (ORIF) right proximal (situated near the point of attachment) femur (large bone in the lower extremity). Resident 7's hospital stay was from 3/17/2023 to 3/20/2023 for three days and was readmitted to the facility on [DATE]. During a review of Resident 7's admission Record (AR- a document containing resident profile information), dated 4/13/2023, indicated, Resident 7 a [AGE] year-old was initially admitted to the facility on [DATE] .dementia (memory loss, poor decision making-skills) .difficulty in walking .muscle weakness .cognitive communication deficit .fall .hypertension (high blood pressure) .macular degeneration (a distortion or loss of central vision) . Resident 7's AR indicated she was readmitted to the facility on [DATE] with a diagnosis of right femur fracture (broken thigh bone). During a review of Resident 7's Minimum Data Set (MDS) assessment, dated 4/13/2023, Section C, indicated, Resident 7's Brief Interview of Mental Status (BIMS) was 3 of 15 points (indicating severe cognitive impairment) .Section G (functional status), and ADL (Activities of Daily Living) Assistance indicated Resident 7 needed .one-person physical assist . for all ADL's. During a review of Resident 7's {name of facility coorporation] Fall Risk Evaluation (AFRE) dated 10/16/2022, (before the fall with injury on 3/17/2023) indicated, .Score: 11 (which indicated Resident 7 was at a medium risk for falls) . During a review of Resident 7's AFRE dated 3/20/2023 (after the fall with injury on 3/17/2023), indicated a .Score: 18 (which indicated Resident 7 was a high risk for falls) . During a review of Resident 7's IDT [interdisciplinary team] Note dated 3/21/2023 indicated .Created Date [Late Entry] 4/17/2023 by SSD [Social Service Department] .IDT met to discuss Resident's fall in bathroom on 3/17/2023 . ambulated with front wheel walker to bathroom. After [Resident 7] used the toilet, nurse witnessed her pull pants up without difficulty.Nurse observed as [Resident 7] attempted to close bathroom door with only one hand on her walker in front of her. [Resident 7] lost her balance and fell onto her right side and slightly backwards landing on right hip . IDT recommends that staff assist all toileting activities . During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with MDSC 1 of Resident 7's Care Plan (CP), dated 4/14/2023, the CP indicated .Focus [Resident 7] has a right hip fracture r/t fall .Date initiated: 3/20/2023 .Goal [Resident 7] will remain free from complications r/t fracture until next review date . Date Initiated: 3/20/2023 .Revision on 3/22/23 .Target Date: 4/9/2023 .Interventions .Give medications as ordered. Monitor/document for side effects and effectiveness .Monitor/document/report PRN [as needed] s/sx [signs/symptoms] or complications related to fracture .Reposition as necessary to prevent skin breakdown. Prevent 90-degree flexion to prevent circulation problems . Focus [Resident 7] has an ADL self-care performance deficit r/t [related to] muscle weakness, advanced Dementia . Date initiated: 5/11/2022 .Revision on 5/28/2022 .Target Date: 4/9/2023 .Interventions .Toilet use: The resident requires limited to extensive assist of (1) staff for toilet use .Focus [Resident 7] is at risk for falls r/t Deconditioning, Gait/balance problems, impaired balance, highly impaired vision, Dementia, ambulatory, wandering behavior .Date initiated: 5/13/2022 .Goal [Resident 7] will be free of minor injury through the review date . Date Initiated: 5/13/2022 .Revision on 5/28/2023 .Target Date: 4/9/2023 .Interventions .Anticipate and meet the resident's needs .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility .Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room .Monitor the resident to ensure use of walker when ambulating to aid in fall prevention .Non slid strips to left side of bed [date initiated 10/17/2022] . PT evaluate and treat as ordered or PRN . The MDSC 1 stated that there was no documentation in the EMR of an IDT meeting or notes. MDSC 1 stated a weekly nurse assessment was done on 3/5/2023 but not after injury. The MDSC 1 stated another weekly nurse assessment should have been done by the licensed nurse on 3/12/2023 but was not done possibly due to hospitalization. The MDSC 1 stated that he was unable to find documentation of any nursing weekly notes after the fall. The MDSC 1 stated it is his expectation that licensed nurses perform weekly assessments for all residents and that any event such as an accident or fall would trigger a head-to-toe assessment be completed. The MDSC1 stated that a fall risk assessment should be completed on admission, and as needed if there is a change in condition and after any falls with a report made to the ADM or DON. The MDSC 1 stated Resident 7's CP did not reflect the IDT recommendations discussed on 3/21/2023. The MDSC 1 stated that the fall could have been prevented if licensed nurses had followed the care plan intervention that indicated that Resident 7 required 1 person assistance during toileting. During a review of the Medication Administration Record (MAR) dated 3/1/2023, the MAR indicated, on 3/20/2023 Resident 7's pain level was a 3 (physician's order dated 5/11/2022 indicated, monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible .) and Acetaminophen (pain reliever) 650 milligrams was administered. Resident 7 reported a pain level of 5 and Acetaminophen 650 milligrams was administered, 3/23/2023 Resident 7 reported a pain level of 4 and Acetaminophen 650 milligrams was administered, 3/25/2023. Resident 7 reported a pain level of 8 and Acetaminophen 650 milligrams was administered, 3/29/2023. Resident 7 reported a pain level of 7 and Acetaminophen 650 milligrams was administered, 3/30/2023. During a review of the Medication Administration Record (MAR) dated 3/1/2023, the MAR indicated, on 3/25/2023 Resident 7's pain level was a 6 (physician's order dated 3/25/2023 indicated, monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible .) and Ibuprofen (pain reliever) 400 milligrams was administered. Resident 7 reported a pain level of 5 and Ibuprofen 400 milligrams was administered, 3/28/2023. Resident 7 reported a pain level of 6 and Ibuprofen 400 milligrams was administered, 3/29/2023. Resident 7 reported a pain level of 8 and Ibuprofen 400 milligrams was administered, 3/31/2023. During a review of the Medication Administration Record (MAR) dated 4/1/2023, the MAR indicated, on 4/4/2023 Resident 7's pain level was a 9 (physician's order dated 5/11/2022 indicated, monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible .) and Tramadol (pain reliever) 50 milligrams was administered. Resident 7 reported a pain level of 9 and Tramadol 50 milligrams was administered, 4/4/2023. Resident 7 reported a pain level of 9 and Tramadol 50 milligrams was administered, 4/5/2023. Resident 7 reported a pain level of 5 and Tramadol 50 milligrams was administered, 4/7/2023. Re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pain management measures were maintained and implemented for one of three sampled residents (Resident 454) when Resident 454 yelled and moaned in pain and staff did not respond when he was calling for help; pain medication was not available upon his admission. This failure resulted in Resident 454 experiencing pain and suffering for prolonged periods of time. Findings: During a concurrent observation and interview with the Unit Manager (UM), on 8/6/19, at 8:15 a.m., through 8:30 a.m., Resident 454's call light was audible and visible out in facility hallway while Registered Nurse (RN) 1, License Vocational Nurse (LVN) 4 and Certified Nursing Assistant (CNA) 4 passed by Resident 454's room and did not respond to Resident 454's call for help. Registered Nurse (RN) 1 was pushing his medication cart in the hallway and passed by Resident 454's room while the call light was sounding and did not respond to Resident 454's call for help. Resident 454 was heard out in the hallway screaming out for help and was loudly moaning in pain. The UM stated Resident 454's call light was on and Resident 454 was clearly heard screaming and moaning in pain out in the hallway and the staff did not respond. The UM stated staff should have answered Resident 454's call for help. During a concurrent observation and interview with the UM, in Resident 454's room, on 8/6/19, at 8:33 a.m., the UM responded to Resident 454's call for help. Resident 454 stated, I have nine out of 10 pain in my stomach. Resident 454 pointed to his abdominal (stomach) binder (a wide compression belt around the abdomen to help improve blood circulation to the surgical location) and stated he had an incision from an abdominal surgery. Resident 454 stated he was upset because the licensed nurses had not given him his pain medication and he was in severe pain. Resident 454 rated his pain as 9 of 10 (a pain scale which indicated a 1 was the mildest pain and a 10 was the worse imaginable). Resident 454 stated, I want to talk to the Administrator (ADM). I want out of this place. I turned the call light on for 30 minutes and nobody is answering my calls for help. I am in so much pain. The UM stated, [Resident 454's] call light should have been answered promptly by staff. The staff that passed by the room should have answered the call light timely especially since [Resident 454] was moaning and complaining of nine out of 10 pain . The facility policy and procedure titled, Answering the Call Light dated 10/2010, indicated, Purpose: The purpose of this procedure is to respond to the resident's requests and needs . 8. Answer the resident's call as soon as possible . Steps in the Procedure . 3. Listen to the resident's request. 4. Do what the resident asks of you, if permitted. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance . During a concurrent observation and interview with RN 1, on 8/6/19, at 8:38 a.m., RN 1 stood next to the medication cart across from Resident 454's room. RN 1 stated he was the nurse assigned to Resident 454. RN 1 stated he walked by Resident 454's room and had not noticed Resident 454's call light was turned on (for 15 minutes). RN 1 stated he should have noticed and responded to Resident 454's call for help. During a review of the clinical record for Resident 454, the face sheet (a document containing resident profile information and medical diagnosis) dated 8/3/19, indicated Resident 454 was admitted to the facility on [DATE] with diagnoses which included t-cell lymphoma (a rare type of cancer affecting specialized white cells called lymphocytes), low back pain, prostate cancer (cancer that affects the prostate gland of the male) intra-abdominal (within the stomach) and pelvic swelling, mass and lump and Infection and inflammatory (swelling) reaction due to cystostomy (surgical creation of an opening into the bladder) catheter (a flexible tube inserted through a narrow opening into a body cavity into the bladder for removing fluid). During a review of the facility document titled, Job Description: Registered Nurse dated 6/2018, indicated, Job Summary: Responsible for the independent supervision of the delivery of care to a group of residents in a nursing unit. Assess resident needs . administer nursing care, evaluate nursing care, and supervise Certified Nursing Assistants and other personnel in the delivery of nursing care . Delivers Resident Care . Promptly respond to call lights and other resident needs . During a concurrent interview with the UM and clinical record review for Resident 454, on 8/6/19, at 8:44 a.m., she reviewed Resident 454's medical diagnosis and stated Resident 454 was admitted to the facility on [DATE] with a diagnosis of abdominal mass and recent surgical removal of a tumor in the abdomen (stomach). The UM reviewed Resident 454's Medication Administration Record (MAR) dated 8/6/19 and stated Resident 454 was administered Norco (narcotic pain medication) on 8/6/19 at 3:53 a.m. The UM reviewed Resident 454's nurse's progress notes dated 8/6/19 at 3:53 a.m. which indicated, . Norco Tablet 5-325 milligrams (mg- a unit of dry measurement) Give 1 tablet by mouth every 4 hours related to Enteropathy (a disease of the small intestine) type T-Cell Lymphoma . low back pain . carcinoma in situ of prostate . The UM stated the nurses note did not have documentation of Resident 454's pain level being re-assessed to make sure the pain medication was effective one hour after Norco was administered at 3:53 a.m. The UM stated, [Licensed Nurses] should have re-assess if the pain medication was effective .it was not done. The UM stated Resident 454 needed his medication for pain and the staff did not respond to his need. During an interview with Resident 454, on 8/6/19, at 10:15 a.m., Resident 454 stated he was admitted to the facility on Saturday, 8/3/19 from the hospital and began to have pain right after his admission to the facility. Resident 454 stated he was in pain for 24 hours until he received his morphine (narcotic pain medication) dose the next day on 8/4/19. Resident 454 stated he received his last dose of morphine at the hospital at 8 a.m. on 8/3/19 and he was supposed to receive a another dose at 8 p.m. when he was admitted to the facility. Resident 454 stated he was in 10 out of 10 pain from 9 p.m. to the time he received a morphine tablet on 8/4/19. Resident 454 stated the morphine medication worked best to relieve his pain. Resident 454 stated I felt like I was being tortured. I wanted to die. It was stabbing pain in my [surgical] incision. Resident 454 stated he can tolerate pain at a seven out of 10 but not 10 out of 10. Resident 454 stated I told the nurses about the pain, but they told me that they did not have the script [written prescription] from the hospital. Resident 454 stated he wanted to be admitted to hospice services [end of life care] because the pain was so bad. Resident 454 stated he did not want to deal with this pain anymore. During a review of the Hospital Medication Administration Record (MAR) for Resident 454, the MAR, dated 8/9/19, indicated morphine sulfate (a controlled narcotic pain medication) 30 mg one tablet was last given in the hospital on 8/3/19 at 8:18 a.m. The Hospital MAR also indicated Norco 5 mg-325 mg two tablets was last given in the hospital on 8/3/19 at 11:27 a.m. During a concurrent interview with LVN 1 and review of the physician orders dated 8/2019 for Resident 454, on 8/7/19, at 9:18 a.m., LVN 1 stated Resident 454 was admitted to the facility on [DATE] at 4 p.m. from the hospital with an admitting diagnosis of an abdominal mass and surgical aftercare for a stomach tumor removal. LVN 1 reviewed the pain medication orders which indicated Norco Tablet 5-325 mg . Give 1 tablet by mouth every 6 hours as needed for T Cell Lymphoma, low back pain . carcinoma in situ [originating from] of prostate . for 14 days and Morphine Sulfate Tablet 30 mg Give 1 tablet by mouth every 12 hours . for chronic pain. LVN 1 stated Resident 454 was admitted to the facility with a triplicate (a written order for controlled narcotic medications) for Norco 5-325 mg and triplicate was faxed to the facility's pharmacy to be filled the prescription. LVN 1 stated the facility had Norco 5-325 mg and 10-325 mg doses available in the emergency kit (a container filled with medications used for new admissions or when routine supply for a resident is not available) for resident use. LVN 1 reviewed the [Nursing] Pain Assessment dated 8/3/19. She stated, when Resident 454 was admitted on [DATE] at 4 p.m., he complained of four out of 10 pain level. Resident 454 complained that he did not receive his pain medication during his admission. LVN 1 stated LVN 1 stated she received authorization from the pharmacy to remove one dose of Norco 5-325 mg from the e-kit during shift change after 9:30 p.m. LVN 1 reviewed the Medication Administration Record (MAR) for August 2019 and stated Resident 454 received Norco 5-325 mg at 10:45 p.m. administered by RN 2 from the e-kit. LVN 1 reviewed the Nurse Note dated 8/3/19 at 8:17 p.m., which indicated, Morphine sulfate ER [extended release] 30 mg tablet . med[ication] not avail[able]. LVN 1 stated Resident 454 did not receive his morphine pain medication on 8/3/19. LVN 1 stated Resident 454 requested hospice care because he did not want to have pain anymore. During a document review titled, [Pharmacy name] Controlled Substance Withdrawal Log dated 8/3/19 at 10:36 p.m., indicated .Item Description . Norco 5-325 [mg] .Quantity Dispensed [one] . During a review of the pharmacy document titled, Proof of [medication] Delivery . dated 8/8/19, indicated Norco 5-325 mg tablet and Morphine sulfate ER 30 mg tablet were delivered to the facility on 8/4/19 at 1:38 a.m. and were available for Resident 454. During a concurrent observation of the Emergency kit (e-kit) on South nursing station, interview with RN 1, and record review for Resident 454, on 8/8/19, at 10:37 a.m., he reviewed the progress note dated 8/3/19 at 8:17 p.m. which indicated morphine sulfate was not available for Resident 454 on admission. RN 1 stated morphine sulfate 30 mg was not available in the e-kit. RN 1 reviewed the e-kit medications and stated the e-kit did contain the medications morphine sulfate 15 mg ER and was available for Resident 454 but RN 1 did not administer the prescribed medication. During a concurrent interview with LVN 1 and record review for Resident 454, on 8/8/19, at 11:11 a.m., LVN 1 stated she was the admission nurse for Resident 454 on 8/3/19. LVN 1 reviewed the progress note dated 8/3/19 at 8:17 p.m. and morphine was not available for Resident 454 on the day of admission. LVN 1 stated after transcribing Resident 454' prescribed medications into and sending the prescribed orders to the pharmacy, the medications would not be delivered until the next day 8/4/19. LVN 1 stated morphine sulfate 30 mg was not available in the e-kit. LVN 1 stated on admission, Resident 454 expressed pain level of four out of 10. LVN 1 stated she checked for his pain during the shift and his pain was changing from eight out of 10 to 10 out of 10. LVN 1 stated she did not document in Resident 454's progress notes of his increased pain level during the shift. LVN 1 stated when she finished her medication pass at around 9:30 p.m., Resident 454 stated his pain was getting worse and was now at a pain level of 10 out of 10. LVN 1 stated she did not call the doctor to ask for a prescription for pain medications to relieve the resident's pain because it would take longer to receive a response from the doctor. LVN 1 stated she had reported the pain issue and informed the RN that Norco could be used to resolve Resident 454's pain medication to the oncoming shift nurse RN 2. LVN 1 stated she should have resolved the Resident 454's pain issues and not left it for the oncoming shift nurse. LVN 1 review the e-kit and stated the medication morphine was available in the e-kit but was not given to Resident 454. LVN 1 stated she should have called the hospital to have the physician write a Triplicate for the medication that was available in the facility e-kit or call the facility physician and asked if they could give the available morphine pain medication one time from the e-kit until the prescription was filled to control the Resident 454's pain. During an interview with CNA 4, on 8/7/19, at 1:16 p.m., she stated, CNA 4 stated Resident 454 was a new resident in the facility and she was informed that he suffered with chronic pain. CNA 4 stated, It's very busy on this side because it's the short term [rehabilitation (rehab- physical therapy)] area. The residents have more needs, they have more pain, we were very busy yesterday [8/6/19]. There was only four CNA's and I had 12 residents yesterday. We are short staff even though we are not full census because the resident acuity [level of severity of an illness] and the needs of all these residents are very high. I was doing care with another resident and somebody told me [Resident 454] was on the [call] light for 15 minutes. Whoever was in the hallway should have answered the call light immediately especially since he (Resident 454) has a lot of pain. During an interview with LVN 4, on 8/7/19, at 2:24 p.m., she stated As soon as the [call] light goes on, everybody should answer the call light. Even nurses have to be aware of call lights and answer it immediately. [Resident 454 waiting for] fifteen minutes is a long time to wait. The call light should have been answered immediately because resident [454] might be in pain . LVN 4 stated she had walked past Resident 454's room on 8/6/19, at around 8:15 a.m., through 8:32 a.m., but did not notice Resident 454's call light was on when she passed by his room. LVN 4 stated she should be watching for call lights and respond to those residents that were calling for help and she did not do that. During an interview with RN 1, on 8/7/19, at 2:28 pm, RN 1 stated, [Resident 454] is in the short term rehab area of the facility. It's always busy there because it's the short term rehab side and residents have more needs. RN 1 stated he should have been aware of call lights and answer call lights promptly especially Resident 454's who was always in pain. RN 1 stated Resident 454 waited 15 minutes before the call light was answered by staff so Resident 454 was very upset. RN 1 stated Resident 454 was in a lot of pain and waiting for pain medication to be administered. During an interview with Resident 454, on 8/7/19, at 3:22 p.m., he stated, When I turned my [call] light on yesterday, it took [staff] one hour to answer my call light. I told her [UM], I was in a lot pain. I told her to tell my nurse I need a pain medication but the nurse did not come back so I turned on the call light and nobody came in. When you saw me yesterday, I was in horrible, horrible pain and waiting for a long time to answer the call light made my pain horrible. I wanted to die at that moment. I have [Clostridioides difficile (C. diff.)- a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon.] and the cramping from the C. diff is really horrible. They took out a big tumor mass in my stomach so I have an incision too that's why I have an abdominal binder too it's just too much pain for me. I am in so much pain and the cramping made it worse. Why did it take them so long to answer the call light? Don't they hear me moaning? I shouldn't have to wait that long for them to help me with my pain. It's horrible pain. I can't take the pain and they did not answer my call light right away; it made the pain really horrible. I had nine out of 10 stomach pain. They should answer my light so they could check me or give me my pain pill. It was time for another pain medication. It was not right for me to wait for such a long time. I shouldn't have to suffer in so much pain if they answered my call light and not wait for a long time. My pain could have been better but they ignored me. During a review of Resident 454's clinical record, the nurse's progress notes dated 8/7/19, at 4:16 a.m., indicated, . Call received from [laboratory] confirming stool positive for C. diff. result faxed to MD [Medical Doctor] . contact precautions in place . During a review of the professional reference titled, C. difficile infection dated 2019 retrieved from https://www.mayoclinic.org/diseases-conditions/c-difficile/symptoms-causes/, indicated C. diff .symptoms include abdomen swelling and pain . During a concurrent interview and record review with the DON, on 8/8/19, at 9:34 a.m., she reviewed Resident 454's MAR dated 8/6/19 and the DON stated Resident 454 was administered Norco 5-325 mg at 3:53 a.m. and he was due to be given another dose at 7:53 a.m. but did not receive that dose. The DON stated Resident 454 was admitted to the facility on [DATE] with a diagnosis of pain so licensed nurses should assess and evaluate Resident 454's pain to evaluate whether the pain medication regimen was effective or not. The DON stated RN 1 should have made his initial rounds to assess Resident 454 for pain so he could medicate him with Norco 5-325 mg. The DON stated, If [Resident 454] was assessed for pain, he could have gotten the pain medication at 7:53 a.m. and he did not. [Resident 454] was in pain and he should have been assessed for pain at the start of the shift [6 a.m.] instead of waiting for the resident to be already in pain. During a review of the clinical record for Resident 454, the care plan dated 8/3/19, indicated, . [Resident 454] has pain related to Prostate [cancer], T-cell lymphoma . Interventions . Administer analgesia [pain medication] as per orders. Give ½ hour before treatments or care . Monitor/document for probable cause of each pain episode. Remove/limit causes of pain where possible . During an interview with the DON, on 8/8/19, at 3:57 p.m., the DON stated she expected the licensed nurses to assess and provide pain medications to residents experiencing pain. The DON stated pain was the fifth vital sign and needed to be addressed by the licensed nurse for Resident 454 once he complained of pain. The DON stated the licensed nurse should have called the doctor to get an order for the morphine that was available in the e-kit and notified the pharmacy of the urgency for the pain medication authorization and did not occur. The DON stated the licensed nurses need to critically think of options to treat and pain management for newly admitted residents. The DON stated the licensed nurse should have acted on the pain issue immediately and they did not. During a telephone interview with RN 2, on 8/9/19, at 9:56 a.m., RN 2 stated when he came on shift at 10 p.m. on 8/3/19, the licensed nurse reported to him Resident 454 was in pain. RN 2 stated Resident 454 had complained to him about pain and not receiving his dose of morphine sulfate on 8/3/19. RN 2 stated the [LVN 1] told him there was an order for Norco 5-325 mg for pain. RN 2 stated when the licensed nurse requests e-kit medication, the licensed nurse would fax the pharmacy requesting authorization to open the e-kit and should follow up within 15 minutes to 20 minutes to the pharmacy to get authorization to access e-kit medications. RN 2 stated the licensed nurse should have checked what was available in the e-kit and notified the doctor for a new order for an emergency dose to relieve pain but no one did that. During a telephone interview with the facility's pharmacist (FP), on 8/9/19, at 11:53 a.m., he stated the pharmacy received Resident 454's admission packet with ordered medications and an emergency request authorization for Norco 5-325 mg one tablet at 4:10 p.m. on 8/3/19. The FP stated the facility sent the triplicate orders for Norco 5-325 mg and morphine sulfate 30 mg. The FP stated there was one request to access the e-kit on 8/3/19 at 4:10 p.m. for Norco 5-325 mg for Resident 454 and one request to access the e-kit on 8/4/19 at 12:12 a.m. also for Norco 5-325 mg for Resident 454. The FP stated the first authorization was given through fax on 8/3/19 at 8:51 p.m. The FP stated the second request was not given due to the routine medication and as needed medication for pain was delivered on 8/4/19 at 1:38 a.m. The FP stated the pharmacy did not receive an authorization request for the medication Morphine on 8/3/19. The facility policy and procedure titled, . Pain Management dated 11/2017, indicated, Purpose: Residents are assessed and evaluated to identify pain and manage pain/symptoms . assist the resident to attain or maintain his/her highest practicable level of well-being . Policy: Quality of care is a fundamental principle that applies to the treatment and care provided to residents. Based on comprehensive assessment of a resident, the facility coordinates care and treatment that are in accordance with evidence based standards of practice, the comprehensive person-centered care plan, the resident's choices as it relates to pain relief or pain management . Guidelines .resident's care plan reflects their individual need and resident choices and preferences in order to help the resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain . Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated. B. Evaluates the existing pain and the cause(s), and c. Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences . Pain Recognition . Expressions of pain .verbal or nonverbal .evaluate residents through complaints of pain, non-verbal indicators, physical symptoms, change in behaviors or loss of function or ADLs . Pain Management . c. Identify and implement resident specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on resident-specific assessment, preferences and choices, a pertinent clinical rationale, and the resident's goals and; using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences. D. Monitor appropriately for effectiveness and/or adverse consequences . including defining how and when to monitor the resident's symptoms and degree of pain relief; and modify the approaches as necessary .

Based on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 960) did not develop pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when preventive measures were not put into place when Resident 960 was assessed as a high risk for developing pressure ulcers and he was not turned and repositioned for more than two hours. Resident 960 was not provided a pressure relief cushion and ongoing skin assessments were not conducted. These failures resulted in Resident 960 developing a preventable Stage 2 (partial-thickness skin loss into but no deeper than the dermis) pressure ulcer to the coccyx (tailbone) area. Findings: During a concurrent observation and interview in Resident 960's room, on 8/6/19, at 8:43 a.m., Resident 960 was lying in bed grimacing and stated, My butt is sore. Resident 960 pressed the call light and the Director Of Nursing (DON) immediately responded and entered Resident 960's room. Resident 960 stated to the DON that his buttocks hurt and the DON repositioned Resident 960. Resident 960's coccyx (tailbone) appeared to have an open wound. The DON assessed the coccyx wound and stated it was a stage 2 pressure ulcer (partial-thickness skin loss caused by pressure over a bony prominence into but no deeper than the dermis). During an observation on 8/6/19, at 9:48 a.m., in Resident 960's room, Resident 960 was transferred (moved) by nursing staff into his wheelchair and left sitting in his room. During an observation on 8/6/19, at 12:11 p.m., in Resident 960's room, Resident 960 remained sitting in his wheelchair with his eyes closed. During an observation on 8/6/19, at 3:45 p.m., in Resident 960's room, Resident 960 remained sitting in the wheelchair and in the same position. During an interview with Licensed Vocational Nurse (LVN) 4, on 8/6/19, at 4:02 p.m., she stated Resident 960 sat in the wheelchair for longer than two hours without being repositioned (off of his tailbone). LVN 4 stated Resident 960 refused to be transferred back to bed. LVN 4 stated Resident 960 should have been repositioned and not left in the same sitting position for such a long time. During an observation on 8/6/19, at 6 p.m., in Resident 960's room, Resident 960 remained sitting in the wheelchair watching television. During an interview with Certified Nurses Aide (CNA) 4, on 8/7/19, at 1:56 p.m., CNA 4 stated Resident 960 sat in the wheelchair for longer than two hours without being repositioned. CNA 4 stated Resident 960 should have been repositioned at least every two hours to prevent the formation of pressure ulcers. CNA 4 stated Resident 960 did not want to go back to bed and the licensed nurse was notified. CNA 4 stated she did not document Resident 960's wishes to remain up in the wheelchair and not be repositioned every 2 hours in Resident 960's clinical record. During a concurrent interview and record review with LVN 4, on 8/7/19, at 2:24 p.m., she reviewed Resident 960's clinical record titled NSG [Nursing] Admission/readmission Evaluation dated 7/8/19, which indicated Resident 960's Braden Score (a tool for predicting pressure ulcer risk) was 17 (at risk for pressure ulcers). LVN 4 stated Resident 960 was at risk to develop pressure ulcers, was incontinent of bowel and bladder and required extensive assistance with one person to turn and reposition in bed. LVN 4 stated Resident 960 should not have sat in the wheelchair for longer than two hours without being repositioned. LVN 4 stated Resident 960 should have been encouraged to transfer back into bed. During a concurrent interview and record review with LVN 4, on 8/7/19, at 2:28 p.m., she reviewed Resident 960's care plan titled, Potential for impairment to skin integrity dated 7/16/19, which indicated Resident 960 would maintain or develop clean and intact skin which included the following interventions to avoid scratching to keep body parts from exposure to excessive moisture ., and to use draw sheet or lifting device to move Resident 960. LVN 4 stated Resident 960's care plan did not address measures to prevent pressure ulcers. LVN 4 stated the care plan should have included repositioning every two hours to prevent pressure ulcers. During a review of the clinical record for Resident 960, the NSG Admission/readmission Evaluation dated 7/8/19, indicated, . Skin . is a skin issue present? Yes . redness to coccyx/buttocks . Bed mobility . The resident requires extensive assistance by (1) staff to turn and repositioning in bed . Transferring . The resident requires Mechanical lift with (2) staff assistance for transfers . During a review of the clinical record for Resident 960, the BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK dated 7/8/19, at 6:42 p.m., indicated, . MOBILITY . Slightly Limited: Makes frequent slight changes in body or extremity position independently . FRICTION & [and] SHEAR . Potential Problem: Moves feebly or requires minimum assistance . Scoring 17 . AT RISK 15-18 . During a review of the clinical record for Resident 960, the Minimum Data Set (MDS) assessment (an evaluation of the resident's cognitive and functional needs) dated 7/15/19, indicated the Resident 960 required two staff members for transfers and was at risk of pressure ulcer development. During a review of professional reference document titled, Pressure Injury Prevention Points dated 2016, retrieved from https://npuap.org/page/PreventionPoints, indicated, Consider bedfast and chairfast individuals to be at risk for development of pressure injury . Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address, repositioning, and support surfaces . During a concurrent interview and record review with LVN 4, on 8/7/19, at 2:32 p.m., she reviewed Resident 960's care plan titled, Pressure ulcer to stage 2 to coccyx r/t [related to] Immobility, and incontinent of bowel and bladder dated 8/6/19, which indicated Resident 960 needed to be turned and/or repositioned frequently. LVN 4 stated the care plan intervention for frequent repositioning should have been initiated on admission when Resident 960 was assessed as at risk to develop pressure ulcers and when the stage 2 pressure ulcer to coccyx area was found on 8/6/19. During an interview with LVN 4, on 8/7/19, at 2:35 p.m., she stated Physical Therapy was not consulted for a pressure relieving wheelchair cushion. LVN 4 stated, I thought Physical Therapy was only for rehab[ilitation]. During an interview with Occupational Therapist (OT) 1, on 8/7/19, at 2:51 p.m., she stated the licensed nurses should have made a referral to OT for a pressure relieving wheelchair cushion. OT 1 stated residents who are at risk to develop pressure ulcer should be repositioned every two hours. During a concurrent interview and record review with the DON, on 8/7/19, at 3:08 p.m., she reviewed Resident 960's clinical record titled, NSG Admission/readmission Evaluation dated 7/8/19, which indicated Resident 960's Braden Score was 17 (high score indicated at risk for pressure ulcer development). The DON stated Resident 960 was at risk to develop pressure ulcers. During a concurrent interview and record review with the DON, on 8/7/19, at 3:15 p.m., she reviewed Resident 960's care plan titled, Potential for impairment to skin integrity dated 7/16/19, which indicated Resident 960 would maintain or develop clean and intact skin. The DON stated the care plan included the use of a draw (half sheet often used to assist with repositioning in bed) sheet or lifting device to move Resident 960. The DON stated the care plan should have included interventions like repositioning every two hours to prevent pressure ulcers and it did not. During a concurrent interview and record review with the DON, on 8/7/19, at 3:20 p.m., she reviewed Resident 960's care plan titled, Pressure ulcer to stage 2 to coccyx r/t Immobility, and incontinent of bowel and bladder, dated 8/6/19, which indicated Resident 960 needed to be turned and repositioned frequently or as often as needed. The DON stated the care plan intervention for repositioning should have been initiated on admission when Resident 960 was assessed as at risk to develop pressure ulcers and when the stage 2 pressure ulcer to coccyx area was found on 8/6/19. The DON stated she forgot to include the intervention for repositioning every two hours in the care plan. During an interview with the DON, on 8/7/19, at 3:25 p.m., she stated Resident 960 sat in the wheelchair for longer than two hours without being repositioned. The DON stated she did not consult Physical Therapy for a pressure relieving wheelchair cushion. The DON stated she did not consider utilizing a pressure relieving wheelchair cushion to reduce the risk for developing pressure ulcers. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on 8/7/19 at 4:02 p.m., she reviewed the clinical record for Resident 960's. The Minimum Data Set (MDS- a resident assessment tool used to identify healthcare needs) dated 7/15/19, indicated Resident 960 needed extensive two-person physical assist with bed mobility and transfer, was incontinent with bladder and bowel and was at risk to develop pressure ulcers. The MDSC stated Resident 960 was at risk to develop pressure ulcer. The MDSC reviewed Resident 960's care plan for skin impairment dated 7/8/19 and stated the care plan had not addressed interventions for pressure ulcer prevention. The MDSC stated frequent repositioning should be in the care plan. The MDSC stated, I should have reviewed the care plan. I should have done better [document interventions]. During a concurrent interview and record review with the MDSC, on 8/8/19, at 1:54 p.m., she reviewed Resident 960's clinical record titled LTC [Long Term Care] Weekly Assessment. The MDSC stated she was unable to find documentation of a weekly skin assessment. The MDSC stated Resident 960 was admitted with redness to his coccyx area. The MDSC stated the licensed nurses should have documented weekly skin assessment to monitor and assess Resident 960's coccyx area. During a telephone interview with LVN 5, on 8/9/19 at 9 a.m., LVN 5 stated she did the admission assessment for Resident 960 on 7/8/19. LVN 5 stated Resident 960 had redness to his coccyx. LVN 5 stated the licensed nurse should have documented a weekly skin assessment to monitor and assess Resident 960 's coccyx area. During a concurrent interview and record review with the DON, on 8/9/19, at 9:40 a.m., she reviewed Resident 960's clinical record titled LTC Weekly Assessment and was unable to find documentation of weekly skin assessments for Resident 960. The DON reviewed the facility policy and procedure titled Quality of Care dated 8/18, which indicated, . The facility will assess resident upon admission, and thereafter, to identify if the resident is at risk for developing or has a PU [Pressure Ulcer]/PI [Pressure Injury], or has pre-existing sign suggesting that tissue damage has already occurred . The DON stated Resident 960 was assessed with redness to his coccyx area on admission and licensed nurse should have done a weekly skin assessment to monitor and assess Resident 960's coccyx area. The DON stated the stage 2 pressure ulcer was new and had not been identified prior to 8/6/19. The DON stated the staff should have performed assessments to ensure the redness did not worsen but no one did that. During a concurrent interview and record review with the DON, on 8/9/19, at 9:50 a.m., she reviewed Resident 960's clinical record titled Care Plan dated 7/8/19, and was unable to find a care plan for redness to coccyx area. The DON stated Resident 960's redness to coccyx area should have been care plan. The DON stated if the redness was care planned the staff would have implemented measures to try to prevent pressure ulcers but they did not do that. The DON stated the stage 2 pressure ulcer was new and could have been prevented if the staff would have addressed the redness. The facility policy and procedure titled QUALITY OF CARE dated 8/18, indicated, To promote the prevention of avoidable pressure ulcers . and provide care and services consistent with professional standards of practice . The facility will implement, monitor and modify interventions to attempt to stabilized, reduce or removed underlying factors . A resident identified as at risk of developing PU [Pressure Ulcer]/PI [Pressure Injuries] will have individualized interventions implemented to prevent PU/PI from developing . The resident's care plan will reflect the interventions . The resident's care plan will reflect the preventative strategies for residents identified as having a PU/PI . The resident's care plan will reflect the treatment strategies for residents identified as having a PU/PI . Prevention and treatment plans will be individualized and consistently provided . Based on the comprehensive assessment and the resident's clinical condition . identified needs . interventions may include . provision of pressure-redistributing support surfaces . if the resident is refusing care . the facility will attempt to identify potential alternatives, as indicated . Repositioning or relieving constant pressure is an effective intervention for treatment or prevention of PU/PIs. Repositioning plans will be addressed in the resident's comprehensive care plan . Repositioning needs to maintain the resident's skin integrity will be considered for residents who are . seated in a chair or wheelchair, as well as for residents who are lying in bed. Repositioning needs/plan will be reflected in the care plan . Pressure redistribution involves both pressure reduction and pressure relief . Pressure redistribution devices (support surfaces/devices) . Facility staff will monitor residents skin condition and be alert to potential changes in the resident's skin condition. Identified changes will be reported . The IDT will develop a relevant care plan that includes measurable goals and interventions for prevention and management of PU/PIs. Identified interventions will be implemented . A weekly evaluation of the PU/PIs will be documented . During a review of professional reference document titled Pressure Injury Prevention Points dated 2016, retrieved from https://npuap.org/page/PreventionPoints, indicated, Consider bedfast and chairfast individuals to be at risk for development of pressure injury . Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address, repositioning, and support surfaces . Inspect the skin at least daily for signs of pressure injury . Assess pressure points, such as the sacrum, coccyx, buttocks . Turn and reposition all individuals at risk for pressure injury . Continue to reposition an individual when placed on any support surfaces . Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs . Reposition weak or immobile .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of the clinical record for Resident 101, the Nursing Progress Note dated [DATE], at 3:14 p.m., indicated, Around [1:45p.m.] was notified by CNA that Resident [101] had fell out of his wheelchair in the hallway while being taken to his dialysis [appointment]. When went to assess, saw Resident [101] laying [sic] face down in the hallway wheelchair. Upon assessment noted Resident [101] bleeding from a laceration [A torn or jagged wound] to left forehead. Pressure to forehead applied. Resident awake but was not responding to writer. When asked what happened, transportation driver [TD] stated, He leaned forward and fell, I tried to grab him from his sweater but couldn't. The record indicated Resident 101 was sent to the hospital emergency room (ER) for evaluation and treatment. The progress note indicated Resident 101 was unable to answer questions when assessed by the nurse. Resident 101 was found lying facedown on the floor with the wheelchair behind him. During an interview with CNA 1, on [DATE], at 11:40 a.m., she stated Resident 101 used a regular wheelchair and had a tendency to lean forward while sitting in the chair. CNA 1 stated Resident 101 always needed to be reminded to sit back in his chair because he would lean forward and he was at risk of falling. CNA 1 stated prior to transportation to the dialysis center, Resident 1 was taken to the nurses' station to be picked up by the transport driver (TD). CNA 1 stated normally a licensed nurse would give a report to the TD before sending Resident 101 to the dialysis center. During an interview with CNA 2, on [DATE], at 12:00 p.m., she stated Resident 1 required a 2 person assist, total transfer and used a mechanical lift (used to move resident who are unable to stand on their own or whose weight makes it unsafe to move) for transfer from the bed to the wheelchair. CNA 2 stated Resident 1 was placed in an upright position and would suddenly move into a slouch position (a gait or posture characterize by an ungainly stooping of the head and shoulder). CNA 2 stated Resident 101 needed assistance to lift himself up because he was unable to do it on his own. CNA 2 stated Resident 101 was taken to the nurses' station on [DATE] when he was ready for transport and waited for the TD to arrive. During a telephone interview with the TD, on [DATE], at 12:50 p.m., the TD stated she arrived to the facility at around 1:20 p.m. on [DATE], to pick up Resident 101 to transport him to the dialysis center. The TD stated she had been picking up Resident 101 to transport to the dialysis unit three times a week for the past two weeks. The TD stated Resident 101 used his own regular wheelchair. The TD stated she saw Resident 101 at the nurses' station awake, but he didn't seem to be his normal self on [DATE] because he would, even when in pain, talk to her about his family. The TD stated the only response she got from Resident 101 was in a low tone ah. The TD stated Resident 1 was sitting in a wheelchair leaning forward wearing an oxygen cannula (tubing placed in the nares connected to an oxygen source). The TD asked for help from the staff to reposition Resident 101 in the wheelchair because he was leaning too far forward, but no one came to assist her. The TD stated when she asked the nurses in the nurses' station if Resident 101 was ready to go to the dialysis center the nurse said yes. The TD stated she told the nurses Resident 101 was leaning too far forward in the chair and a nurse responded, He [Resident 101] always does that. The TD stated she was not trained to reposition residents and would be unable to reposition the resident safely. The TD stated she was only the transport driver. The TD stated she had asked Resident 101 to sit back but Resident 101 did not respond. The TD stated as she wheeled Resident 101 out of the facility, approximately 5 yards from the nurses' station, Resident 101 leaned forward and fell out of the wheelchair. The TD stated she was not fast enough to catch Resident 101. The TD stated when she called for help two nurses arrived and picked up Resident 101. The TD stated Resident 101's face was covered in blood. During an interview with the DON, on [DATE], at 3:00 p.m., she stated, Resident [101] does not lean forward. It was not reported to TD because positioning was not an issue. The DON stated she was not notified about Resident 101's leaning forward while sitting in his wheelchair on [DATE]. During a review of the clinical record for Resident 101, the Face sheet dated [DATE], indicated Resident 101 was admitted to the facility [DATE] with diagnoses which included End Stage Renal Disease (ESRD) (a person's kidneys cease functioning on a permanent basis), hypertension, anemia, transient ischemic attack, type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dependence on renal dialysis (mechanical removal of waste, salt, and extra water to prevent them from building up in the body). During a review of the clinical record for Resident 101, the MDS assessment dated [DATE], indicated Resident 101's BIMS score was 14 of 15 points, which indicated Resident 101 was cognitively intact (pertaining to memory, judgement, and reasoning). The MDS assessment indicated Resident 101 required extensive assistance in bed mobility, movement on unit and off unit, dressing, and personal hygiene. The MDS assessment indicated Resident 101 required total staff assistance with transfer from bed to chair and on and off the toilet. The MDS assessment indicated Resident 101 was unsteady when moving from one surface to another and was only able to stabilize with staff assistance. During a telephone interview with TD, on [DATE], at 6:13 p.m., she stated I was not given report about Resident 101's condition and proper positioning. TD stated she should have waited for the nurses to help her position Resident 101 in his wheelchair. TD stated she should have waited for the nurses to give a proper report about Resident 101's health condition before taking Resident 101 down the hallway. TD stated the fall could have been avoided If the staff would have made sure Resident 101 was checked and made sure he was safe to take to his dialysis appointment. TD stated no one came to help Resident 101 when she asked the staff for help him sit right or to check him to make sure he was okay to go to dialysis. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on [DATE], at 3:45 p.m., LVN 2 stated she was the nurse assigned to Resident 101 on [DATE]. LVN 2 stated at around 1:38 pm she was notified by a CNA that Resident 101 fell out of his wheelchair in the hallway while being taken to dialysis unit. LVN 2 stated when she arrived, Resident 101 was lying face down in front of his wheelchair and bleeding profusely from a laceration to his left forehead. LVN 2 applied a pressure dressing to his forehead. LVN 2 stated Resident 101 was awake but not responding when asked a question. The Unit Manager (UM) had also arrived and was assisting. The UM directed LVN 2 to call EMS (emergency medical services- emergency services which treats illnesses and injuries that requires an urgent medical response). LVN 2 stated she notified the doctor and attempted to contact all emergency contacts of Resident 101's family but no response, so she left a voice message. LVN2 stated vital signs (pulse rate, body temperature, respiration rate, and blood pressure,) at 1:03 showed a (blood pressure of (the pressure caused by your heart contract and the pressure when your heart relaxes and fills with blood )149/79, pulse rate at (the number of times your heart beats in one minute) 61 beats per minute and temperature at 97.8 Fahrenheit which was taken before TD wheeled the patient out of the facility. LVN 2 stated she saw the TD twice in the facility to pick up Resident 101 and assumed she knew the condition of Resident 101 because she was the regular driver who had transported Resident 101 to dialysis in the past. LVN 2 stated she did communicate with the driver to give report on Resident 101. LVN 2 stated she did not have a conversation with the driver prior to incident. She spoke with the driver after the incident and asked the driver what had happened. LVN 2 stated TD told her that Resident 101 leaned forward and fell out of the wheelchair. TD tried to grab him from his sweater but was unable to catch him. LVN 2 stated the nurse only gave TD report if it was a new driver who was not familiar with the resident. LVN 2 stated the TD who came to pick up residents for appointments usually communicates with the licensed nurse and asks about behavior and mental status of the resident. During a review of the hospital clinical record for Resident 101, the Hospital History and Physical dated [DATE], indicated, [Resident 101] sustained a fall at [facility] . Pt [patient] was in a chair and fell flat on to his face. Most likely syncopal episode .Pt came to ER [Emergency Room] as trauma. Had a large laceration above L [left] eyebrow s/p [status post] repair in ER During a review of the Hospital clinical record for Resident 101, the CT [Computed tomography-Detailed images of internal organs [brain] obtained by this type of X-ray device] dated [DATE], indicated FINDINGS: Brain: there is a 3 mm [millimeter- unit of measurement] acute/subacute [sudden onset or rapid change] subdural hematoma [ a condition in which blood collects on the brain's surface beneath the skull] along the right aspect of the falx [brain] . During an interview with LVN 2, on [DATE], at 3:55 p.m., LVN 2 stated Resident 101 had a history of falls and on [DATE] Resident 101 he had a fall at the dialysis center which required resident to be hospitalized . LVN 2 stated Resident 101 returned from the hospital to the facility on [DATE] with a new diagnosis of Syncope (temporary loss of consciousness caused by a fall in blood pressure) and Anemia (low levels of healthy red blood cells to carry oxygen throughout the body). LVN 2 reviewed Resident 101's clinical record and stated the new diagnosis were not added to the existing conditions. LVN 2 reviewed Resident 101's care plans and stated care plans for leaning forward, syncope or anemia were not developed. LVN 2 stated Resident 101 had a known high risk for falls and a care plan was very important to identify care needs and person centered interventions that could have prevented Resident 101 from falling again. LVN 2 stated the new diagnosis would add to Resident 101's risk for falls and should have been added to the fall care plan with interventions to minimize the risk for further falls. LVN 2 stated no one added the diagnosis to the care plan. LVN 2 stated she did not remember if she referred Resident 101 back to physical and occupational therapy for evaluation for leaning forward while sitting in the wheelchair to evaluate possible positioning devices. LVN 2 stated, There are days when I see him lean forward and other days when he does not. I do not remember if he leaned forward on that date [[DATE]]. During a concurrent interview and record review with Occupational Therapist (OT) 1, on [DATE], at 10:15 p.m., she reviewed the facility clinical record titled Occupational Therapy Treatment Encounter note(s) dated [DATE], which indicated Resident 101 presented with poor sitting balance to the left side. OT 1 stated Resident 101 was encouraged to sit straight and the goal was to sit upright while in his wheelchair. OT 1 stated interventions to promote proper upright sitting were trunk control exercises and placing a pillow on his left side. OT 1 stated Resident 101 was unable to continue his therapy treatment because he had experienced dizziness spells on [DATE], [DATE], and [DATE] and the licensed nurse in charge of Resident 101 was notified. OT 1 stated she notified nursing multiple about the poor body posture and episodes of dizziness either verbally or in a written note. OT 1 stated Resident 101's health condition was declining and he was not making progress in occupational therapy, so he was referred to restorative nursing services for strengthening exercises on [DATE]. During a review of the clinical record for Resident 101, the Occupational Therapy OT Evaluation & [and] Plan of Treatment dated [DATE], indicated .Diagnoses . Abnormal Posture . Initial Assessment . Cognitive-Communicative assessment . other cognitive function Safety Awareness . impaired . Reason for Therapy . facilitate sitting tolerance and postural control . During a review of the clinical record for Resident 101, the Physical Therapy PT Evaluation & Plan of Treatment dated [DATE], indicated .Neuromuscular Assessment Sitting Balance Static Sitting = [equal] Poor + [positive], Dynamic Sitting = Poor During a review of the clinical record for Resident 101, the Occupational Therapy OT Evaluation & Plan of Treatment dated [DATE], indicated .Summary of Daily Skilled Services . [Resident 101] presenting with poor sitting balance leaning to left side . fell to left side with max [maximum] assist needed to reposition to midline . During a review of the clinical record for Resident 101, the Occupational Therapy OT Evaluation & Plan of Treatment dated [DATE], indicated .Summary of Daily Skilled Services . [Resident 101] reporting being very dizzy and unable to sit up W/C [wheelchair] level longer than 15 min [minutes] due to increasing dizziness .charge nurse notified and in room attending to [Resident 101] . During a review of the clinical record for Resident 101, the Physical Therapy Treatment Encounter Note(s) dated [DATE], indicated .Summary of Daily Skilled Services . Pt [Patient] with increased dizziness when up in wc [wheelchair] BP [blood pressure] unable to assessed and pt [patient] returned to bed. Transfer with max. A [maximum Assist] . During a review of the clinical record for Resident 101, the Physical Therapy Treatment Encounter Note(s) dated [DATE], indicated .Summary of Daily Skilled Services . Pt [Patient] did not have the strength to hold himself using the chair and was very disappointed in himself and the realization that he has gotten so much weaker I believe has finally hit him as he made the comment how come I can't sit up anymore by myself and why can't I transfer like I used too . During a concurrent interview and record review with Director of Rehabilitation (DOR), on [DATE], at 11:10 a.m., she stated Resident 101's poor sitting posture and dizziness was discussed during their daily stand up meeting with the IDT. The DOR was unable to recall if she reported the leaning to the sides while sitting in a wheelchair. The DOR was unable to find IDT notes in Resident 101's clinical record regarding Resident 101 leaning to the sides while sitting in a wheelchair. During a concurrent interview and record review with the Unit Manager (UM), on [DATE], at 2:40 p.m., UM reviewed Resident 101's nurses notes and stated Resident 101 had previously had multiple falls and the staff knew he was a risk for falls. she reviewed the progress notes regarding Resident 101's fall that occurred on [DATE]. The UM stated Resident 101 was sitting in a chair in the dialysis center lobby when he fell. The UM stated there was no communication with the dialysis center to get details on how he fell. The UM stated Resident 101 was sent to the hospital on [DATE] from the dialysis center and was hospitalized from [DATE] to [DATE]. The UM stated Resident 101 was admitted back to the facility on [DATE] with new diagnoses of syncope and anemia. The UM stated IDT did not meet to discuss the fall nor to find the root cause of the fall and implement new interventions to prevent further falls. The UM stated IDT did not meet to discuss the new diagnoses of syncope and anemia and did not update the care plan with new interventions. The UM stated there should have been an IDT meeting to analyze the fall and new diagnoses of syncope and anemia. The UM stated she would expect the fall at the dialysis center to be care planned to document his history of falls. The UM stated the diagnoses of syncope and anemia placed the resident at high risk for additional falls. During a telephone interview with the Dialysis Registered Nurse (DRN), on [DATE], at 3:05 p.m., she stated on [DATE], while Resident 101 was waiting in the dialysis lobby, the unit clerk saw the resident doubled over (suddenly bend forward) with his chest against his lap and head down. The DRN stated the unit clerk observed Resident 101 falling onto the floor. During an interview with the Administrator (ADM), UM, and DON, on [DATE], 3:54 p.m., the ADM stated IDT did not discuss Resident 101's dizziness nor leaning posture during daily clinical meetings with the DOR. The ADM stated if it was not documented in the IDT progress note, then it was not discussed during the meeting. The UM stated the licensed nurses have access to view therapy documentation a couple of days after the therapy session was completed. The UM stated the licensed nurses should use the daily therapy documentation to be informed on how the resident was progressing or if there were changes in condition from the resident's baseline. The DON stated Resident 101 had previous falls and staff were aware of his fall risk. The DON stated the IDT should have reviewed the fall that occurred at the dialysis center to discuss the new diagnoses of syncope and anemia and implement interventions to reduce the risk from falling related to syncope but the IDT did not meet and interventions were not implemented. The facility policy and procedure titled, Quality of Care Accident Hazards/ Supervision/Devices dated 7/17, indicated . 6. Efforts to minimize risk to residents will include individualized, resident-centered interventions .8. Individualized interventions will be developed to reduce the potential for accidents. 9 . a. Identification . b. Evaluation . c. Analysis to identify the root causes .Falls . 2. When a resident experiences a fall, the facility will evaluate potential causal factors to aid in the development and implementation of relevant, consistent and individualized interventions to reduce the likelihood of future occurrences. 3. The facility will initiate and implement a comprehensive, resident-centered fall prevention plan for residents at risk for falls or with a history of falls . Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered care plan for four of 10 sampled residents (Residents 46, 460, 101, and 60) when: 1. Resident 46 had a total of 21 falls between [DATE] and [DATE] and licensed nursing staff did not develop an individualized fall prevention care plan and implement effective interventions after each fall to prevent additional falls. These failures led to Resident 46's twenty-first fall on [DATE] which resulted in a nondisplaced fracture (the bone breaks either part or all of the way through but maintains its proper alignment) of distal nasal bone and uncontrolled nasal bleeding for a three-hour period. 2. Resident 460 was assessed as having impulsive behaviors, with poor safety awareness. Resident 460 was assessed as requiring two-person assistance with transfers, extensive assistance of one staff with dressing and toileting, and limited assistance with ambulation. Resident 460 had a total of 21 falls between [DATE] through [DATE]. Fall risk prevention interventions for Resident 460's assessed needs were not developed and implemented on the care plan. This failure resulted in Resident 460 sustaining a skin tear to his nose and bleeding from the right knee after the 14th fall and a skin tear on top of the left hand after the 19th fall. 3. Resident 101 was admitted to the facility on [DATE] with diagnoses of syncope (temporary loss of consciousness) and anemia (low red blood cells) and care plan interventions were not developed to prevent falls. This failure resulted in Resident 101 falling on [DATE], transported to the hospital for treatment of the head injuries and died after 5 days ([DATE]). 4. Resident 60's medication, nitroglycerin (treat and prevent chest pain), did not have an individualized care plan. This failure had the potential for Resident 60 to not receive appropriate care and needs to be able to attain the highest well-being. Findings: 1. During a review of the clinical record for Resident 46, the Face sheet (a document with personal identifiable information) dated [DATE], indicated Resident 46 was admitted to the facility on [DATE] with medical diagnoses of dementia (a chronic or persistent disorder of the mental processes marked by memory disorder, personality changes, and impaired reasoning), repeated falls, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), hypertension (high blood pressure), and transient ischemic disease (a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain). During a review of the clinical record for Resident 46, the Minimum Data Set (MDS) assessment (a resident assessment tool used to develop a plan of care) dated [DATE], indicated Resident 46's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) score was 5 of 15 points, which indicated severe cognitive (pertaining to memory, judgement, and reasoning) impairment. The MDS assessment indicated Resident 46 required extensive assistance (staff provided weight-bearing support) to transfer from bed to chair. The MDS assessment indicated Resident 46 was unsteady when moving from one surface to another and was only stabilized with staff assistance. During an observation on [DATE], at 8:10 a.m., Resident 46 propelled himself in a wheelchair between two rooms across from the nurses' station. During an interview with Certified Nursing Assistant (CNA) 8, on [DATE], at 8:15 a.m., he stated Resident 46 was at high risk for falls and fell two weeks ago. During an interview with CNA 9, on [DATE], at 8:24 a.m., she stated Resident 46 had more than one fall. Resident 46 had poor balance and was unsteady when he walked. Resident 46 required assistance of one person when transferring from the bed to the wheelchair and to the toilet. During an interview with Resident 46, with non-English speaking staff present, (CNA 9), on [DATE] at 8:30 a.m., Resident 46 stated he did not use the call light but yelled for help if assistance was needed. CNA 9 stated Resident 46 did not use his call light to ask for help when needed because he had confusion and did not know how to use the call light. During an interview with CNA 9, on [DATE], at 8:43 a.m., she stated Resident 46 had a short term memory problem and had difficulty following direction. Resident 46 had multiple episodes of attempting to transfer himself from the bed without assistance. CNA 9 stated Resident 46 could take short steps but was unable to walk independently and used a wheelchair to move around. Resident 46 was able to hold his weight while standing beside the toilet when assisted by one person. During an interview with the Unit Manager (UM), on [DATE], at 8:51 a.m., she stated Resident 46 was pleasantly confused and was unable follow directions due to his confusion. During an interview with the Director of Nursing (DON), on [DATE], at 8:55 a.m., she stated after Resident 46's last fall on [DATE], a shorter wheelchair was provided, and dycem (a non-slip material) was placed on Resident 46's seat cushion. During a concurrent observation and interview with CNA 10, on [DATE], at 10 a.m., she stated, I can't remember when the dycem was in place. Right now he [Resident 46] doesn't have one. CNA 10 stated most of the falls happened during transfers. During a concurrent interview and record review with the DON on [DATE], at 10:36 a.m., she stated Resident 46 had 21 falls between [DATE] and [DATE]. Twelve of 21 falls happened when the resident fell from the wheelchair on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] (x2), and [DATE]. Eight of 21 falls occurred from the bed on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. One of the 21 falls happened ([DATE]) when Resident 46 was ambulating. During a concurrent interview with the DON and the Minimum Data Set Coordinator (MDSC), on [DATE], at 10:40 a.m., the DON stated each of Resident 46's falls should have had a new intervention written on the care plan to attempt prevention of further falls. The DON stated the care plan did not have fall prevention interventions after each fall. During an interview with LVN 8, on [DATE] at 11:04 a.m., he stated each fall should have a short term care plan with individualized goals and interventions. LVN 8 stated when the short term care plan was resolved the applicable intervention would then be added to the long term care plan. LVN 8 reviewed the fall care plan and stated interventions after each fall were not implemented to prevent additional falls. LVN 8 stated the interventions that were added to the care plan would not prevent falls. During an interview with LVN 8, on [DATE], at 11:19 a.m., LVN 8 stated he had been providing care to Resident 46 for less than a year. LVN 8 stated Resident 46 required one staff to assist with activities of daily living (ADLs). LVN 8 stated it was not safe for Resident 46 to transfer without assistance as he was confused most of the time. LVN 8 stated Resident 46 called for help verbally when in the wheelchair and bed, and waved at staff for help. LVN 8 stated, Not even one moment that he [Resident 46] used his call light to my knowledge. LVN 8 stated a new intervention that was not previously used should have been added to the fall care plan after every fall. LVN 8 stated new interventions were added to the fall care plan but none of the interventions added would prevent falls. During a concurrent interview and record review with the DON on [DATE], at 1:53 p.m., she provided a fall care plan in which the interventions listed were marked with the date when the fall happened. The care plan intervention indicated, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Date Initiated [DATE]. During a review of the facility policy and procedure titled, Falls and Fall Risk, Managing dated 12/07, indicated, Policy Statement [:] Based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Prioritizing Approaches to Managing Falls and Fall Risk . 1, The staff . will identify appropriate interventions to reduce the risk of fall . 4. If falling recurs despite initial interventions, staff will implement additional of different interventions . 5. staff will try various interventions . until falling is reduced or stopped, or until the reason for continuation of falling is identified as unavoidable . During an interview with the DON, on [DATE], at 2:20 p.m., the DON stated, The resident has the potential to sustain a new injury without a new intervention in place. The DON was asked if the care planning policy was followed for falls that occurred without new documented interventions. The DON responded, No. During an interview with the DON on [DATE], at 11:04 a.m., the DON stated Resident 46 was assessed as having a BIMS score of 5 (cognitive impairment). The DON stated the intervention to encourage the usage of the call light was not appropriate for Resident 46 as he was unable to remember the instruction. The DON stated using this intervention alone would not prevent a fall and was not safe for the resident. The DON stated if an appropriate intervention were developed and implemented after each fall, succeeding falls could have decreased. The DON stated an intervention should be patient-centered and focused on the resident's specific needs and that did not occur. During a concurrent interview and record review with the DON on [DATE], at 12:15 p.m., she stated on [DATE] (Fall # 10) Resident 46 fell from the wheelchair. The care plan intervention following this fall, indicated, Demonstrated to resident how to use the call light and had resident demonstrated back. Make sure call light is within reach. The DON stated using a call light or demonstrating the use of a call light was a generic intervention and not a patient-centered intervention that would not prevent falls. During a concurrent interview and record review with the DON, on [DATE], at 12:30 p.m., she stated on [DATE] (Fall #11) Resident 46 fell from the bed. The care plan intervention indicated, Continues to educate the importance of calling for assistance to prevent further falls. The DON stated the intervention listed was not appropriate because Resident 46 had difficulty following direction, making his needs known and was confused. The DON stated the intervention would not prevent falls. During a concurrent interview and record review with the DON, on [DATE], at 2:05 p.m., the DON reviewed the care plan for falls and stated on [DATE] (Fall #11) Resident 46 fell from his bed. The DON stated, I don't know why there was no intervention developed for this fall. During a concurrent interview and record review with the DON, on [DATE], at 2:07 p.m., she stated on [DATE] (Fall #13) Resident 46 fell from a wheelchair. The fall care plan intervention indicated, Continue to encourage resident to use call light or to call for help and until help is arrive. The DON stated the use of a call light had been the intervention used repeatedly on previous falls and would not prevent additional falls. During a concurrent interview and record review with the DON, on [DATE], at 2:10 p.m., she stated on [DATE] (Fall #14) Resident 46 fell from the wheelchair. The fall care plan intervention indicated, Notify MD [Medical Doctor] for acute changes. The DON stated, No, it [new intervention added] does not prevent a fall from happening. During a concurrent interview and record review with the DON, on [DATE], at 2:20 p.m., she stated on [DATE] (Fall #16) Resident 46 fell from the bed. The intervention added to the care plan at that time was frequent monitoring. The DON stated, Frequent monitoring has been used [before]. No, it's not a new intervention. During a concurrent interview and record review with the DON, on [DATE], at 2:23 p.m., she stated on [DATE] (Fall #17 & 18) Resident 46 fell from the wheelchair twice on this date. The fall care plan intervention dated [DATE] indicated, Reinforce and replace dycem as needed. The DON stated Resident 46 kept removing the dycem from the wheelchair. The dycem was used during the first fall on [DATE], and no intervention was added after the falls of [DATE]. During a concurrent interview and record review with the DON, on [DATE], at 2:23 p.m., she stated on [DATE] (Fall #20) Resident 46 fell from the bed. The care plan for falls indicated, Continue interventions on at risk care plan. The DON stated there were no new interventions developed or added to the care plan. The DON stated not all falls have a new intervention. During a concurrent interview and record review with the DON, on [DATE], at 2:35 pm, she stated on [DATE] Resident 46 fell from bed while trying to reach for his wheelchair across the room. A nas[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of the clinical record for Resident 101, the Nursing Progress Note dated 5/16/19, at 3:14 p.m., indicated, Around [1:45 p.m.] was notified by CNA that Resident [101] had fell out of his wheelchair in the hallway while being taken to Dialysis [process of removing waste products and excess fluid from the body] .saw Resident [101] laying [sic] face down in the hallway wheelchair. Upon assessment noted Resident [101] bleeding from a laceration [A torn or jagged wound] to left forehead. Pressure to forehead applied. Resident awake but was not responding to writer. When asked what happened, transportation driver [TD] stated he leaned forward and fell, I tried to grab him from his sweater but couldn't. MD [Medical Doctor] notified of incident. Resident sent out to ER [Emergency Room] for further evaluation . During a review of the clinical record for Resident 101, the Nursing Progress Note dated 5/16/19, at 3:32 p.m., indicated, .writer was called to front hallway by staff for assistance with a fall around [1:48 p.m.] .approached Resident [101] he was lying face down wheelchair behind him. Resident [101] seemed to have lost consciousness while on the floor . This writer was asking resident questions, he was not able to answer, but able to open eyes when calling his name .had laceration with blood coming from top of left eyebrow . EMS [Emergency Medical Services] arrived . apply neck collar and transfer onto a back board . During an interview with CNA 1, on 6/21/19, at 11:40 a.m., she stated Resident 101 used a regular wheelchair and had a tendency to lean forward. CNA 1 stated Resident 101 always needed to be reminded to sit back in his chair because he would lean forward and was at risk for falling. CNA 1 stated prior to transportation to the dialysis center, Resident 1 was taken to the nurses' station to be picked up by the transport driver (TD). CNA 1 stated, A licensed nurse gives a report to [TD] before sending [Resident 101] to the dialysis center. During an interview with CNA 2, on 6/21/19, at 12:00 p.m., she stated Resident 1 required 2-person physical assistance with transfers and used the mechanical lift (device used to move resident who are unable to stand on their own or whose weight makes it unsafe to move) for transfer from bed to wheelchair. CNA 2 stated Resident 1 was placed in an upright position and would suddenly move into a slouch position (a posture characterized by an stooping of the head and shoulder). CNA 2 stated Resident 101 needed assistance to lift himself up because he was unable to do it on his own. CNA 2 stated Resident 101 was always taken to the nurses' station when he was ready for dialysis transport and waited for the TD to arrive. During a telephone interview with the TD, on 6/21/19, at 12:50 p.m., TD stated she arrived to the facility at around 1:20 p.m. on 5/16/19, to pick up Resident 101 to go for his dialysis treatment. TD stated she had been picking up Resident 101 from the facility to transport to the dialysis unit three times a week for the last two weeks. TD stated Resident 101 used his own regular wheelchair. TD stated she saw Resident 101 at the nurses' station awake, but didn't seem to be his normal self because Resident 101 usually talks to her about his family even if he was in pain. This time, his responses were a low tone ah. TD stated when she asked how he was doing he responded with an ah which was not his normal self. TD stated Resident 1 was sitting in a wheelchair leaning forward with oxygen connected through nasal cannula (oxygen tubing connected to resident nose). TD asked for help from the staff to position Resident 101 in the wheelchair because he las leaning forward too far, but no one came to help her. TD stated she asked the nurses in the nurses' station (TD did not know the nurses name) if Resident 101 was ready to go to the dialysis unit and the nurse responded yes. TD stated she told the nurses that Resident 101 was leaning forward too far and a nurse responded, He [Resident 101] always does that. TD stated she was not trained to reposition residents and would be unable to reposition Resident 101 safely. TD asked the resident to sit back but Resident 101 did not respond. TD stated her main responsibility was to make sure resident [101] arrived to his dialysis appointment on time. TD sated she saw a binder and lunch bag at the back of the wheelchair and knew Resident 101 was ready to go. TD stated as she wheeled Resident 101 out of the facility, approximately 5 yards from the nurses' station, Resident 101 leaned forward and fell out of the wheelchair. TD stated she was not fast enough to catch Resident 101. TD stated she asked for help and two nurses came and picked up Resident 101 with his face covered in blood. After the fall TD stated she was instructed by the nurse to leave the facility because Resident 101 was not going to dialysis During a telephone interview with Transportation Company Supervisor (TCS), on 6/21/19 at 1:05 p.m., he stated the facility staff should have checked Resident 101 and should have given a proper report to the driver. TCO stated My driver (TD) has no medial background to know if Resident 101 was well enough to be transported to the dialysis center. During an interview with DON, on 6/21/19, at 3:00 p.m., she stated Resident 101's CNA checked the appointment book and Resident 101 was scheduled for dialysis treatment on 5/16/19. DON stated the CNA prepared Resident 101 for his dialysis appointment and placed him in front of the nurses' station while waiting for transport. CNA placed the lunch bag, cell phone and the communication binder (a record that provides communication between the facility and the dialysis center) on the back of his wheelchair indicating Resident 101 was ready for transport to dialysis. DON stated, We do not give verbal reports to the TD because the communication binder for dialysis is already in the bag. DON stated Resident [101] does not lean forward. It was not reported to TD because positioning was not an issue. DON stated she was not notified about Resident 101's leaning forward issue while sitting on his wheelchair. During a review of the clinical record for Resident 101, the Face sheet dated 6/21/19, indicated Resident 101 was admitted to the facility 3/29/19 with diagnoses which included End Stage Renal Disease (ESRD) (a person's kidneys cease functioning on a permanent basis), hypertension, anemia, transient ischemic attack, type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dependence on renal dialysis (mechanical removal of waste, salt, and extra water to prevent them from building up in the body). During a review of the clinical record for Resident 101, the MDS assessment dated [DATE], indicated Resident 101's BIMS score was 14 of 15 points, which indicated Resident 101 was cognitively intact (pertaining to memory, judgement, and reasoning). The MDS assessment indicated Resident 101 required extensive assistance in bed mobility, movement on unit and off unit, dressing, and personal hygiene. The MDS assessment indicated Resident 101 required total staff assistance with transfer from bed to chair and on and off the toilet. The MDS assessment indicated Resident 101 was unsteady when moving from one surface to another and was only able to stabilize with staff assistance. During a telephone interview with TD, on 7/8/19, at 6:13 p.m., she stated I was not given report about Resident 101's condition and proper positioning. TD stated she should have waited for the nurses to help her position Resident 101 in his wheelchair. TD stated she should have waited for the nurses to give a proper report about Resident 101's health condition before taking Resident 101 down the hallway. TD stated the fall could have been avoided if the staff would have made sure Resident 101 was checked and made sure he was safe to take to his dialysis appointment. TD stated no one came to help Resident 101 when she asked the staff for help. During a concurrent interview and record review with LVN 2, on 8/6/19, at 3:45 p.m., LVN 2 stated she was the nurse assigned to Resident 101 on 5/16/19. LVN 2 stated at around 1:38 pm she was notified by a CNA that Resident 101 fell out of his wheelchair in the hallway while being taken to dialysis unit. LVN 2 stated when she arrived, Resident 101 was lying face down in front of his wheelchair and bleeding profusely from a laceration to his left forehead. LVN 2 applied a pressure dressing to his forehead. LVN 2 stated Resident 101 was awake but not responding when asked a question. The Unit Manager (UM) had also arrived to help with the fall and was assisting. The UM directed LVN 2 to call EMS (emergency medical services- transport service which transports and treats illnesses and injuries that requires an urgent medical response). LVN 2 stated she notified the doctor and attempted to contact all emergency contacts of Resident 101's family but no response, so she left a voice message. LVN2 stated vital signs (pulse rate, body temperature, respiration rate, and blood pressure,) at 1:03 showed a (blood pressure of (the pressure caused by your heart contract and the pressure when your heart relaxes and fills with blood )149/79, pulse rate at (the number of times your heart beats in one minute) 61 beats per minute and temperature at 97.8 Fahrenheit which was taken before TD wheeled the patient out of the facility. LVN 2 stated she saw the TD twice in the facility to transport Resident 101 and assumed she knew the condition of Resident 101 because she was the regular driver who had transported Resident 101 to dialysis in the past. LVN 2 stated she did communicate with the driver to give report on Resident 101. LVN 2 stated she did not have a conversation with the driver prior to the incident. She spoke with the driver after the incident and asked the driver what had happened. LVN 2 stated TD told her that Resident 101 leaned forward and fell out of the wheelchair. LVN 2 stated TD tried to grab him from his sweater but was unable to catch him. LVN 2 stated nurses would give report to transport drivers only if the driver was not familiar with the resident. During a review of the hospital clinical record for Resident 101, the Hospital History and Physical dated 5/16/19, indicated, [Resident 101] sustained a fall at [facility] . Pt [patient] was in a chair and fell flat on to his face. Most likely syncopal episode .Pt came to ER [Emergency Room] as trauma. Had a large laceration above L [left] eyebrow s/p [status post] repair in ER During a review of the Hospital clinical record for Resident 101, the CT [Computed tomography-Detailed images of internal organs [brain] obtained by this type of X-ray device] dated 5/16/19, indicated FINDINGS: Brain: there is a 3 mm [millimeter- unit of measurement] acute/subacute [sudden onset or rapid change] subdural hematoma [ a condition in which blood collects on the brain's surface beneath the skull] along the right aspect of the falx [brain] . During an interview with LVN 2, on 8/7/19, at 3:55 p.m., LVN 2 stated Resident 101 had a history of falls and on 5/7/19 Resident 101 had a fall at the dialysis center which required resident to be hospitalized . LVN 2 stated Resident 101 returned from the hospital to the facility on 5/13/19 with a new diagnosis of Syncope (temporary loss of consciousness caused by decreased blood flow to the brain) and Anemia (low levels of healthy red blood cells to carry oxygen throughout the body). LVN 2 reviewed Resident 101's clinical record and stated the new diagnosis was not added to the existing medical diagnosis. LVN 2 reviewed Resident 101's care plans and stated care plans for leaning forward, syncope or anemia were not developed and should have been developed to prevent falls. LVN 2 stated Resident 101 had a known high risk for falls and a care plan was important to identify care needs and person centered interventions that could have prevented Resident 101 from falling. LVN 2 stated the new diagnosis would add to Resident 101's risk for falls and should have been added to the fall care plan with interventions to minimize the risk for further falls. During a concurrent interview and record review with OT 1, on 8/7/19, at 10:15 p.m., she reviewed the facility clinical record titled Occupational Therapy Treatment Encounter note(s) dated 4/18/19, which indicated Resident 101 had a history of poor sitting balance to the left side. OT 1 stated Resident 101 was encouraged to sit straight and the goal was to sit upright while in his wheelchair. OT 1 stated interventions to promote proper upright sitting were trunk control exercises and placing a pillow on his left side. OT 1 stated Resident 101 was unable to continue his therapy treatment because he had experienced dizziness spells on 4/11/19, 4/14/19, and 4/19/19 and the licensed nurse in charge of Resident 101 was notified. OT 1 stated she notified nursing multiple times about Resident 101's poor body posture while sitting in the wheelchair and episodes of dizziness either verbally or in a written note. OT 1 stated Resident 101's health condition was declining and he was not making progress in occupational therapy, so he was referred to restorative nursing services for strengthening exercises on 4/22/19. During a review of the clinical record for Resident 101, the Occupational Therapy Evaluation & [and] Plan of Treatment dated 4/11/19, indicated .Diagnoses . Abnormal Posture . Initial Assessment . Cognitive-Communicative assessment . other cognitive function Safety Awareness . impaired . Reason for Therapy . facilitate sitting tolerance and postural control . During a review of the clinical record for Resident 101, the Physical Therapy [PT] Evaluation & Plan of Treatment dated 4/12/19, indicated .Neuromuscular Assessment Sitting Balance Static Sitting = [equal] Poor + [positive], Dynamic Sitting = Poor During a review of the clinical record for Resident 101, the Occupational Therapy Evaluation & Plan of Treatment dated 4/18/19, indicated .Summary of Daily Skilled Services . [Resident 101] presenting with poor sitting balance leaning to left side . fell to left side with max [maximum] assist needed to reposition to midline . During a review of the clinical record for Resident 101, the Occupational Therapy Evaluation & Plan of Treatment dated 4/19/19, indicated .Summary of Daily Skilled Services . [Resident 101] reporting being very dizzy and unable to sit up W/C [wheelchair] level longer than 15 min [minutes] due to increasing dizziness .charge nurse notified and in room attending to [Resident 101] . During a review of the clinical record for Resident 101, the Physical Therapy Treatment Encounter Note(s) dated 4/19/19, indicated .Summary of Daily Skilled Services . Pt [Patient] with increased dizziness when up in wc [wheelchair] BP [blood pressure] unable to assessed and pt [patient] returned to bed. Transfer with max. A [maximum Assist] . During a review of the clinical record for Resident 101, the Physical Therapy Treatment Encounter Note(s) dated 4/23/19, indicated .Summary of Daily Skilled Services . Pt [Patient] did not have the strength to hold himself using the chair and was very disappointed in himself and the realization that he has gotten so much weaker I believe has finally hit him as he made the comment how come I can't sit up anymore by myself and why can't I transfer like I used too? . During a concurrent interview and record review with Director of Rehabilitation (DOR), on 8/7/19, at 11:10 a.m., she stated Resident 101's poor sitting posture and dizziness was discussed during their daily stand up meeting with the IDT. The DOR was unable to recall if she reported the leaning to the sides while sitting in a wheelchair. The DOR was unable to find IDT notes in Resident 101's clinical record regarding Resident 101 leaning to the sides while sitting in a wheelchair. During a concurrent interview and record review with the UM, on 8/7/19, at 2:40 p.m., UM reviewed Resident 101's nurses notes and stated Resident 101 had previously had multiple falls and the staff knew he was a risk for falls. she reviewed the progress notes regarding Resident 101's fall that occurred on 5/7/19. The UM stated Resident 101 was sitting in a chair in the dialysis center lobby when he fell. The UM stated there was no communication with the dialysis center to get details on how he fell. The UM stated Resident 101 was sent to the hospital on 5/7/19 from the dialysis center and was hospitalized from [DATE] to 5/13/19. The UM stated Resident 101 was admitted back to the facility on 5/13/19 with new diagnoses of syncope and anemia. The UM stated IDT did not meet to discuss the fall nor to find the root cause of the fall and implement new interventions to prevent further falls. The UM stated IDT did not meet to discuss the new diagnoses of syncope and anemia and did not update the care plan with new interventions. The UM stated there should have been an IDT meeting to analyze the fall and new diagnoses of syncope and anemia. The UM stated she would expect the fall at the dialysis center to be care planned to document his history of falls. The UM stated the diagnoses of syncope and anemia placed the resident at high risk for additional falls. During a telephone interview with the Dialysis Registered Nurse (DRN), on 8/7/19, at 3:05 p.m., she stated on 5/7/19, while Resident 101 was waiting in the dialysis lobby, the unit clerk saw the resident doubled over (suddenly bend forward) with his chest against his lap and head down. The DRN stated the unit clerk observed Resident 101 falling onto the floor. During an interview with the Administrator (ADM), UM, and DON, on 8/7/19, 3:54 p.m., the ADM stated IDT did not discuss Resident 101's dizziness nor leaning posture during daily clinical meetings with the DOR. The ADM stated if it was not documented in the IDT progress note, then it was not discussed during the meeting. The UM stated the licensed nurses should use the daily therapy documentation to be informed on how the resident was progressing or if there were changes in condition from the resident's baseline. The DON stated Resident 101 had previous falls and staff were aware of his fall risk. The DON stated the IDT should have reviewed the fall that occurred at the dialysis center to discuss the new diagnoses of syncope and anemia and implement interventions in the care plan to reduce the risk from falling related to syncope but the IDT did not meet and interventions were not implemented in the care plan. The facility policy and procedure titled, Quality of Care Accident Hazards/ Supervision/Devices dated 7/17, indicated . 6. Efforts to minimize risk to residents will include individualized, resident-centered interventions .8. Individualized interventions will be developed to reduce the potential for accidents. 9 . a. Identification . b. Evaluation . c. Analysis to identify the root causes .Falls . 2. When a resident experiences a fall, the facility will evaluate potential causal factors to aid in the development and implementation of relevant, consistent and individualized interventions to reduce the likelihood of future occurrences. 3. The facility will initiate and implement a comprehensive, resident-centered fall prevention plan for residents at risk for falls or with a history of falls . The facility policy and procedure titled, Comprehensive Care Plans dated 11/17, indicated, Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychological need . The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person centered care plan for each resident . Guidelines: 1. The care plan . It will drive the typical care and services that a resident receives and will describe the resident's . needs and preferences; as well as how the facility will assist in meeting these needs and preferences . 7. The care plan will be person-specific with measurable objectives, interventions, and timeframe. It will address goals, preferences, needs, and strengths of the resident. The services the facility will provide to assist the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being . The facility policy and procedure titled, Comprehensive Care Plans dated 11/17, indicated, Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychological need . The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person centered care plan for each resident . Guidelines: 1. The care plan . It will drive the typical care and services that a resident receives and will describe the resident's . needs and preferences; as well as how the facility will assist in meeting these needs and preferences . 7. The care plan will be person-specific with measurable objectives, interventions, and timeframe. It will address goals, preferences, needs, and strengths of the resident. The services the facility will provide to assist the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being . 2. During a concurrent observation and interview with Family Member (FM) 1, in Resident 29's room, on 4/24/19, at 12:25 p.m., Resident 29 was lying in bed and was unable to answer questions or greetings. Resident 29's FM 1 was sitting at his bed side. FM stated she was visiting her husband on 4/22/19 and the staff told her that her husband spilled his coffee on himself and burned his legs. FM 1 pulled back the covers exposing Resident 29's legs. Resident 29's right and left upper thighs were wrapped in white gauze. FM 1 became tearful stated The burns [to the right and left thigh] are bad. FM 1 stated Resident 29 got the burns while he was in the activity room on 4/22/19 at 10 a.m. FM 1 stated Resident 29 was given a cup of hot coffee and he spilled it on his legs. FM 1 stated I come every day to see [Resident 29] and help him eat .he shakes . FM 1 stated the staff told her Resident 29 was in the activity room and was given a cup of hot coffee in a regular one handled cup and spilled the coffee on his thighs. FM 1 stated she did not remember who told her she was so warried about her husband. During a review of the clinical record for Resident 29, the face sheet indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, muscle wasting, muscle weakness, dysarthria (difficult or unclear articulation of speech). During a review of the clinical record for Resident 29, the MDS assessment dated [DATE], indicated Resident 29 's BIMS score was two out of 15 which indicated Resident 29 suffered from severe cognitive impairment. The MDS assessment section G indicated Resident 29 required one-person physical assistance from staff for mobility, and eating. During an interview with CNA 13, on 4/24/19, at 12:45 p.m., she stated I have been caring for Resident 29 for two years and [I] am familiar with his care and needs. Resident 29 is able to feed himself at times, but needs supervision and assistance. CNA 13 stated Resident 29's shake and he cannot move. CNA 13 stated Resident 29 should have a two handled spill proof sippy cup for all drinks (hot or cold) because Resident 29's hands are unsteady and shake all the time. CNA 13 stated all residents with adaptive equipment cups were to be provided the correct cups to prevent injuries. During a concurrent interview with LVN 9 and review of Resident 29's clinical record, on 4/24/19, at 1:20 p.m., LVN 9 stated reviewed Resident 29's progress notes dated 4/22/19 at 10:30 a.m., and stated CNA 13 came to her to report Resident 29 had marks to his thighs and was sitting in his wheelchair in his room. LVN 9 stated when she entered Resident 29's room, Occupational Therapist (OT) 2 was with Resident 29. LVN 9 stated OT 2 informed her that Resident 29 had spilled his hot coffee on himself in the dining room. LVN 9 stated she conducted an assessment of the Resident 29's thighs. LVN 9 stated Resident 29's thighs had burns to large areas of both of his thighs. LVN 9 reviewed Resident 29's progress note and stated she documented her findings in Resident 29's progress note on 4/22/19 at 11:33 a.m. which indicated Resident 29 had red areas on right upper thigh measuring 26 centimeters (cm - unit of measure) x (by) 17.5 cm with blister (a small bubble on the skin filled with serum and caused by friction, burning, or other damage). LVN 9 stated Resident 29 had a red area on the right inner thigh measuring 12 cm x 6.5 cm, a red area on top of the thigh with blister measuring 2 cm. x 4 cm., and a red area to left upper thigh measuring 12 cm x 10 cm with a blister measuring 5 cm x 2 cm. During an interview with the DON, on 4/24/19, at 2:55 p.m., she stated, I was alerted to the hot coffee spill injury by [LVN 9] on 4/22/19 at 9:30 a.m. The DON stated I did not go see Resident 29 or see his injuries and I should have . The DON stated LVN 9 had informed her that Resident 29 had burns to his thighs. The DON stated she did not conduct an assessment or investigated how the accident occurred. During an interview with Activities Assistant (AA), on 4/25/19, at 1:30 p.m., she stated I provide refreshments for residents who come to activities. The AA stated Resident 29 was brought to activities by staff three to four times a week. The AA stated Resident 29 has minimal participation during activities because he is unable to talk to others and his movements are stiff. The AA stated Resident 29 preferred to drink hot coffee or hot chocolate in the activity/dining room. AA stated the kitchen staff gave her a pot of hot water and a pot of hot coffee. AA stated she prepared the drinks for the resident sin the activities room. AA stated she poured Resident 29's hot coffee into a two handled cup. During a telephone interview with Occupational Therapist (OT) 2, on 4/26/19, at 11:36 a.m., she stated Resident 29 was on her caseload for therapy services and was looking for Resident 29 on 4/22/19. OT 2 stated walked into the activity room and saw Resident 29 at a corner end of the room trying to stand from his wheelchair. OT 2 stated she alerted AA to help Resident 29 before he fell. OT 2 stated she and AA walked toward Resident 29 and saw Resident 29 with his shirt and pants wet. OT 2 stated Resident 29 seemed agitated and was trying to stand up which was something Resident 29 was unable to normally do. OT 2 stated due to Resident 29's diagnosis of Parkinson's masked face (loss of facial expressions, loss of motor control in facial muscles) he was unable to make expressions or speak clearly. OT 2 stated she took Resident 29 back to his room by wheelchair to be changed. OT 2 stated CNA 13 helped her remove Resident 29's pants and saw his legs were really red and blistered. OT 2 stated both her and CNA 13 were surprised and CNA 13 rushed to go get the nurse for Resident 29. OT 2 stated she remained with Resident 29 until the nurse arrived to the room and then she left Resident 29 under the care of his nurse. During a telephone interview with the Activities Director (AD), on 4/26/19, at 11:48 a.m., she stated I did not see the incident when [Resident 29] spilled his coffee because I was in a meeting. The AD stated she spoke with the Activities Assistant (AA) who was present at the time of the incident. The AD stated the AA served Resident 29 hot coffee in a two handled sippy cup with a few pieces of ice. The AD stated the two handled sippy cup had a big hole where Resident 29 could drink from. The AD stated AA informed her that AA left the two handled sippy cup with hot coffee on the table next to Resident 1 and walked away to serve other residents in the activity room. The AD stated the AA informed her that she had added a few pieces of ice in the hot coffee because the coffee was really hot. During an interview with AA, on 4/29/19, at 18:15 a.m., The AA stated on 4/22/18 Resident 29 was sitting alone at a table when she served Resident 29 coffee in a two handled sippy cup because Resident 29 has tremors to both of his hands. AA stated after she served Resident 29 his coffee she walked away and continued to serve all other resident in the activity room their drinks. AA stated her back was turned toward Resident 29 as she was interacting and serving other residents. AA stated the OT 2 walked into the activity room and told her to look at Resident 29 because he was trying to stand up from his wheelchair. AA stated Resident 29 was not able to stand on his own so she was surprised. AA stated she and OT 2 ran to help Resident 29 sit back down and noticed Resident 29's shirt and pants were wet. AA stated Resident 29 was not able to tell her what happened but he was very anxious and his eyes were wide open like he was surprised. AA stated she touched Resident 29's pants and they were hot from the spilled coffee. AA stated I found the two handled sippy cup under the table where [Resident 29] sitting at with the lid on and empty. AA stated the two handled sippy cup could hold six ounces of fluid. AA stated, The coffee I served him was really hot .I have been burned myself with the hot coffee in the past. AA stated OT 2 took Resident 29 to his room to change him. AA stated she knew he had spilled his hot coffee on himself. AA stated she did not call the nurse for help when she and OT 2 found Resident 29 wet with hot coffee spilled on him in the activity room. AA stated she knew he was hurting because of the look on his face and she knew the coffee she served him was very hot. AA stated she should have called the nurse to the activity room and immediately got help for Resident 29 but she did not do that. AA stated she panicked. AA stated she did not know Resident 29 needed help drinking his hot coffee. AA stated she was the only staff member in the activity room and she had to continue serving all of the other residents in the activity room. AA stated she did not have anyone to help her. AA stated she was the only person in the activity room providing supervision and serving all of the residents. AA stated no one had informed her that she had to serve Resident 29 in a none spilled sippy cup. During a concurrent interview and demonstration with AA, on 5/1/19, at 9:15 a.m., AA demonstrated the two handled sippy cup she used to serve coffee 's coffee for Resident 29 on 4/22/19. AA stated This is the cup used for Resident 29 on 4/22/19. AA filled the two handled sippy cup with water and poured the water out of the spout into the sink. AA stated This cup is not a non-drip cup. During the demonstration a large amount of water freely flowed out of the two handled sippy cup pout. During a review of the clinical record for Resident 29, the care plan titled Potential Nutritional Problem dated 7/30/16, indicated Beverages are served in [a] 2-handled spill proof cups .Eats in Assisted dining room . During a review of the facility policy and procedure titled Assistive Devices dated 9/2017, indicated, Appropriate assistive devices/utensils will be provided as indicated in the individualized plan of care to maintain or improve a resident's/patient's ability to .drink independently . During an interview with LVN 2, on 5/1/19, at 9:35 a.m. she stated Resident 29 should have had supervision at all times when eating and drinking. LVN 2 stated staff should have stood by to assist Resident 29 while he was drink[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify discharge needs and develop a discharge care plan for one of 31 sampled residents, (Resident 565) when Resident 565 was discharged to a board and care home without ensuring the board and care home was capable of meeting Resident 565's needs. The facility Interdisciplinary Team (IDT, a team of healthcare providers who meet to plan resident care) did not meet to evaluate Resident 565's need for a safe discharge. Resident 565 was discharged to the board and care home which could not provide Resident 565 with required assistance for bathing and grooming. Resident 565 was transferred without adequate discharge planning, discharge teaching or emotional preparation. As a result of these failures, Resident 565 was not provided with necessary assistance to meet her hygiene and bathing needs and suffered from emotional distress from lack of planning and preparation. Findings: Resident 565's clinical record titled, Face Sheet (record containing resident personal information) indicated Resident 565 was a [AGE] year old female who was admitted to the Skilled Nursing Facility (SNF) on 10/18/17. The Face Sheet indicated Resident 565 had diagnoses that included Hemiplegia (paralysis of one side of the body) affecting the left side, Pain and Weakness. The Face Sheet indicated Resident 565 was discharged on 3/26/18 to Private home/apt. Resident 565's clinical record titled, Minimum Data Set (MDS, an assessment tool used to plan resident care) Assessment dated 3/26/18 (date of discharge), indicated Resident 565 had moderate cognitive (pertaining to memory, reasoning and judgement) impairment and required extensive staff assistance for bed mobility (turning side to side and repositioning), dressing, toilet use, personal hygiene (combing hair, brushing teeth) and was totally dependent on staff assistance for bathing. The MDS indicated Resident 565 had not walked in her room in the 7 days prior to discharge. On 4/19/18 at 9:10 a.m., during an interview, the facility Administrator (Adm) stated the facility was notified by Medi-Cal that Resident 565 would no longer be covered [Medi-Cal would no longer pay for Resident 565's stay in the SNF] effective November 2018. The Adm stated the facility used a placement agency (PA) to find a facility that would accept Resident 565 and the PA arranged placement at the board and care home. The Adm stated the maintenance staff and social services staff drove Resident 565 to the board and care home on 3/26/18 in the facility bus. The Adm stated she thought Resident 565 would do fine in the board and care home. The Adm stated, I did not know that she needs help with hygiene and showers. On 4/19/18 at 9:23 a.m., during an interview, the Assistant Social Services Director (ASSD) stated, Medi-Cal will not renew [Resident 565] benefit so we needed to find her a place. Her coverage ends in November of this year. The ASSD stated shortly after the facility found out Resident 565's Medi-Cal coverage would end, the PA notified the facility that a board and care was available and someone would come out to speak to Resident 565. The ASSD stated, I guess a guy came in and evaluated [Resident 565]. I didn't get to meet the guy from that board and care place. [Resident 565] and her roommate both said a guy came in. The ASSD stated, I didn't have a good feeling about it [the discharge to board and care]. [Resident 565] had a stroke and so I can see why she would need help with her shower. [Resident 565] was surprised she was accepted [by the board and care] with her left sided paralysis. She was low income. She was getting $800 monthly so she didn't have many options for places to go to. On 4/19/18 at 10:13 a.m., during an interview, Certified Nursing Assistant (CNA) 6 stated she was the CNA regularly assigned to provide care to Resident 565 while she was in the SNF. CNA 6 stated Resident 565 was wheelchair bound most of the time, but could walk short distances with assistance wearing a leg brace and using a special walker. CNA 6 stated, She needs help to fasten her briefs (adult garment for incontinence). She definitely needs help with her shower. On 4/25/18 at 10:04 a.m., during an interview, the PA Senior Care Coordinator (SCC) stated she had worked as an in-home care giver for one year and three months before going to the PA as a care coordinator. The SCC stated the PA usually assesses a resident before they attempt to find placement. The SCC stated she and two other PA employees were at the SNF a few days before Resident 565 was discharged . The SCC stated, [Resident 565] was in the activity room so we were unable to talk to her or assess her. [The ASSD] told us not to bother [Resident 565] when she was playing bingo. No, we didn't get to talk to [Resident 565] prior to her discharge. On 4/25/18 at 4:18 p.m., during an interview, the ASSD stated she did not see the PA staff go into Resident 565's room, but the Licensed Nurse Care Coordinator (LNCC) with the PA contacted her and said the board and care home was available for Resident 565. The ASSD stated, In a matter of four days the discharge happened. The nurse called for the discharge order, the Medical Director (MD), and that was that. The ASSD stated the MD ordered home health to follow Resident 565 after discharge. Resident 565's clinical record titled, Physician's Orders dated 3/22/18, indicated, Pt [patient] to D/C [discharge] to [name of facility] board and care on 3/26/18. Will need home health RN [registered nurse] PT [physical therapy] for medication management, progressive strengthening and mobility. D/C with meds [medication]. F/U [follow-up] with PCP [primary care provider] in one week. Will need standard wheelchair for 99 + days. The order was signed by the MD. Resident 565's clinical record titled, Progress Notes dated 3/19/18 indicated, [PA] in today to attempt to find placement for [Resident 565]. Medi-Cal will not pay for her stay. Information provided and [PA] will follow up in finding placement if possible. Resident 565's Progress Note dated 3/22/18, indicated, [PA] a facility Board and Care will accept [Resident 565]. Resident 565's Progress Note dated 3/26/18 at 4 p.m., indicated [Resident 565] was transported to [board and care] today. Transported by the facility bus. Social Service assisted and helped with all personal items. Helped [Resident 565] settle into her new room, helped with clothing. The Progress Note was signed by the ASSD. On 4/25/18 at 4:51 p.m., during a telephone interview, board and care staff member (BCSM) stated he lived at the board and care home with his girlfriend. The BCSM stated, What we do for each person: we cook three meals, clean the bathrooms, wash clothes once a week. This is independent living. We are not caregivers. I went to [the SNF] and talked to [Resident 565]. I told her that our place is for independent living. I asked her to check it out first before she decides. The [facility staff] brought [Resident 565] the same day I came to visit her. I was actually surprised. We are not caregivers here so I like the potential client to check first. The BCSM stated the ASSD accompanied Resident 565 on 3/26/18 when she was transferred to the board and care home. The BCSM stated, After bringing in [Resident 565]'s belongings, [the ASSD] left when [Resident 565] was busy talking to other residents. Around dinner time [Resident 565] was looking for [the ASSD]. She said she was getting hungry and needed to go back to [the SNF]. I told her [the ASSD] left earlier and she was not coming back, that [Resident 565] would be living here now. She got very upset and teary. She was going on and on saying, She dumped me. She dumped me. On 4/25/18 at 5:10 p.m., during a telephone interview, Resident 565 stated, That day [3/26/18] [the ASSD] packed up my belongings, I thought I was going to be moved to a different room or a different part of [the SNF]. The paper that I signed and everything they did and asked me to do were all for the move to a different part [of the SNF]. Later in the day [the ASSD] took me here [board and care home]. I thought we were just checking the place out because [the BCSM] told me that I needed to check this place first because he said it is for independent living. I told him I need help getting cleaned. That's when he said to check it out to see if it would work for me. Before I knew it, [the ASSD] dumped me. I did not get any teachings. She dumped me here. The [ASSD] told me home health will be coming over to help me; but nobody has come. I've had one shower in three weeks because my son came to visit with his wife so my daughter-in-law helped me. Then I have this powder medication that I don't know anything about. Nobody told me anything about it so I'm not taking it. I am so confused because the bottle has my name on it but there is also the word pediatric on it and I know pediatric means children and I am not one. I can't get ahold of my son and it's always like that with him. I can't depend on him to help me. Resident 565 stated she had a stroke in 1998 and could get up for a short distance wearing a leg brace and using a cane. Resident 565 stated when she resided at the SNF the CNAs would wake her up at 2:15 a.m. every day, help her put on her leg brace and walk her to the bathroom. Resident 565 stated at the board and care home she was unable to get her leg brace on by herself quickly. Resident 565 stated, By the time I get it [the leg brace] on I already wet myself. Resident 565 stated she did not have any incontinence briefs available the first two days she resided at the board and care. Resident 565 stated, [The ASSD] didn't tell me that she was going to dump me here. She told me that we were just checking out the place, then she left. I was looking for her around dinner time to go back to [the SNF]. [The BCSM] told me she left and I'm staying. I was so upset. She tricked me. I can't shower by myself. I am not prepared to come here at all yet. I am not even able to wheel myself to the store because it is a dangerous area. [The ASSD] keeps telling me that they will take care of me but that's not what they do here. They can't. They are not caregivers. On 4/25/18 at 5:22 p.m., during a telephone interview, the home health agency account executive (HHA) stated, We have not started our service with [Resident 565] because we do not have updated doctor's orders. The HHA stated they could not accept orders from the facility medical director, the order for home health services had to come from the resident's primary physician and those orders were not received. On 4/25/18 at 7:28 p.m., during a telephone interview, the PA Owner ([NAME]) stated, Our assessment [for placement of a resident] is basically an interview, not a physical assessment. We sit down with the patient, social worker and discharge planner to come up to a decision what's the best placement for the patient. I remember we were told that [Resident 565] was independent and limited income. That's why she was referred to room and board [board and care]. The final decision is up to the [SNF] administrator. On 4/26/18 at 10:36 a.m., during a telephone interview, the Director of Nursing (DON) stated, I didn't know that [the PA] did not assess [Resident 565]. I did know after the fact that the [home health agency] had not gone out to visit yet. There was not a lot of teaching needed for [Resident 565]. Placement was set up, transportation was arranged. There was nothing to teach her or nothing else. The nurse went over the medications and made sure she understood. The ASSD did [Resident 565]'s discharge. She did it within seven days. I did not know that the nurse who discharged [Resident 565] did not do a return demonstration when she went over the medications. Return demonstration is necessary to be sure that what you taught the resident or what you were discussing with that resident was understood clearly. On 4/26/18 at 10:50 a.m., during a telephone interview, Licensed Nurse (LN) 6 stated she was the nurse who discharged Resident 565 on 3/26/18. LN 6 stated, I went over her medications .No I did not have her do it [show how to set up her medications]. I should have done a return demonstration. On 4/26/18 at 11:02 a.m., during a telephone interview the Social Services Director (SSD) stated, I spoke with home health this morning. She said finally they got their paperwork .for [Resident 565]'s in-home support [one month after the discharge]. On 4/26/18 at 2:48 p.m., during a telephone interview, the DON stated the facility IDT did not meet to plan Resident 565's discharge. The DON stated, It happened pretty quickly, the discharge. I admit we probably didn't do all the necessary steps. I did not check the regulations on discharge. The DON stated the SNF had IDT meetings on a daily basis, but had not met to plan a safe discharge for Resident 565. Resident 565's clinical record titled Post Discharge Plan dated 3/26/18, indicated under Social Services Information: Family/Resident Involved with discharge planning: a box indicating no was checked. The Sections of the Post Discharge Plan for nutritional notes, immunization information, home exercises, doctor in charge of resident's care after discharge, follow-up doctor's appointments, resident training for home and notification of the Long Term Care Ombudsman (resident advocate who by regulation should be notified of all facility initiated discharges) were all left blank. Review of the facility Policy titled Care Planning - Interdisciplinary Team dated Revised September 2013, indicated Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietitian; d. The Social Services Worker; e. The Activity Director/Coordinator; f. Therapists; g. Consultants; h. The Director of Nursing; i. The Charge Nurse; j. Nursing Assistants; k. Others as appropriate or necessary to meet the needs of the resident. 3. The resident, the resident's family .are encouraged to participate in the development of and revisions to the resident's care plan. The facility policy titled, Comprehensive Care Plans dated 11/20/17 indicated, Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs. Policy: The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical, mental, and psychosocial needs that are identified in the comprehensive assessment .8. Care plan will include: d. ii. The resident's preference and potential for discharge to the community. NOTE: Facility will document assessments related to return to community and referrals to local agencies. The facility policy titled, Discharging the Resident dated December 2016, indicated .Preparation: 1. The resident should be consulted about the discharge .4. If discharging the resident to another long-term care facility tell the resident: d. Who will be providing the resident's care .f. Why the discharge is necessary .7. Assess and document resident's condition at discharge .