**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents were protected from accidents and hazards when: One of two residents sampled for falls with injuries (Resident 9), was transferred by staff from her bed to her wheelchair, without using the proper equipment. Two of three shower rooms were observed to have unlocked, open cabinets that contained disposable razors and a sharps container (a plastic safety container for needles and sharp objects), that was over spilling with used razors.These failures resulted in Resident 9 sustaining a broken ankle and had the potential for residents who used the shower rooms to be injured by cuts from razors which could negatively impact residents physical and emotional well-being. 1. Resident 9 was admitted to the facility for heart disease with heart failure, lymphoma (a form of blood cancer), a history of falling, cervicalgia (back pain), osteoporosis (brittle bones), and an above the knee amputated (surgically removed) left leg. Review of Resident 9’s care plans (undated) indicated that staff should use Resident 9's, “Procedures for Transfer,” which were printed and taped near Resident 9's bedside with instructions for the Certified Nursing Assistants (CNAs) on how to safely transfer Resident 9 using a slide board (a plastic or wooden flat board that assists those who cannot stand by sliding across the board to transfer in and out of bed). Resident 9’s care plan indicated, “7. [Resident 9] can lean to the left while using slide board,” and that slide board was necessary to transfer Resident 9 safely. Review of Resident 9’s Minimum Data Set (MDS, a panel of assessments to determine the level of care needed for a resident), section GG “Functional Abilities,” performed on 4/27/25 indicated that Resident 9 was “dependent” (needed complete assistance) for a bed-to-chair transfer. Review of the facility’s record titled, “Shift Report” (undated), an informational sheet CNA's used for the level of care a resident needs, indicated that Resident 9 was a “two person assist,” using a “slide board.” Review of the facility’s Occupational Therapy department’s record titled, “OT Daily Documentation,” dated 11/25/24, indicated that Resident 9 required a slide board for CNA staff to transfer her and that education and demonstration using the slide board had been provided to staff. A review of Occupational Therapy notes from 12/1/24 to 7/1/25 indicated Resident 1 was a, “moderate” to “maximum assist” with transfers using a slide board in all instances. Review of Resident 9’s Nurses Notes dated 7/1/25, indicated that on 7/1/25 at 11:30 AM CNA A was attempting to transfer Resident 9 from her bed to a wheelchair without the use of a slide board, the resident [Resident 9] slid to the bed, injuring her ankle. A review of Resident 9’s progress notes dated 7/11/25 at 11:30 AM, indicated that CNA A was helping transfer Resident 9 from her bed to her wheelchair. CNA A directed Resident 9 to stand up on her right leg to make the transfer, instead of using the slide board. Resident 9 was not able to bear her weight on one leg, her only leg, and fell and broke her right ankle. The progress note indicated that Resident 9’s right ankle became swollen and bruised and she had to go to the hospital emergency room for treatment. Review of the hospital emergency room notes, dated 7/12/25, indicated that Resident 9 had sustained a, “fracture [broken] of the right ankle.” Resident 9's right ankle was put in an orthopedic boot (a splint that keeps the ankle from moving), and returned back to the facility. In an interview on 7/21/25 at 1:39 PM, Resident 9’s family member (FAM) N confirmed that Resident 9 was always transferred using a slide board and that the instructions were posted right next to Resident 9's bed. In an interview on 7/22/25 at 10:05 AM, CNA A confirmed that she had transferred Resident 9 on 7/11/25, without using a slide board, and confirmed she had been instructed to always use the slide board when transferring Resident 9. CNA A confirmed that she had not asked another staff to help her transfer Resident 9 and confirmed that she knew two staff were required but attempted to transfer Resident 9 by herself. CNA A stated that on 7/11/25, Resident 9 expressed she did not want to use the slide board and CNA A chose to stand Resident 9 up on one leg to transfer her. CNA A stated that she should have asked the nurse what to do when Resident 9 didn't want to use the slide board, because there were no instructions on what to do if Resident 9 refused to be transferred with the slide board. In an interview on 7/22/25 at 10:27 AM, Occupational Therapist (OT) B stated, When we worked with [Resident 9], we recommended a slide board be used because of her knee pain and having only one leg, it relieved the pressure on her knee. She is at least a two-person assist for patient and staff safety. If a resident refuses to use the board to transfer, they should 1) Get help, or 2) speak to their resident and let her know that we would need to use a Hoyer (mechanical) lift, which is also a two person assist. In an interview on 7/24/25 at 11:00 AM, OT C stated that she worked with Resident 9 for nine months on transferring safely. OT C stated, “She needed the slide board because of her knee pain, we shouldn’t be doing ‘stand and pivot’ transfers because they torque [twist] the knee and ankle, and she only had that leg to stand on.” OT C stated that the slide board was recommended for Resident 9’s safety and for staff safety. “We did in-services [training] with nursing assistant staff working with the resident [Resident 9], to transfer her safely. Somedays she refused, the remedy was just to spend more time with resident to persuade her to allow the slide board to be used.” In an interview with Director of Nursing (DON) on 7/22/25 at 3:00 PM, DON indicated that the standard of care used by the facility for transferring residents is the, “Lippincott procedures” (undated), an online nursing resource. A review of Lippincott procedures, “Transfer from Bed to Wheelchair,” (undated) provided by the facility indicated, “For a patient who can’t stand, a transfer board allows safe transfer from a bed to a wheelchair;” and; “Assess the patient’s needs and abilities when making decisions about the necessary equipment for transfer, because different patients require varying levels of assistance with transfer.” The [NAME] further indicated, “A lateral patient transfer can pose risks to the patient and health care worker. Safe patient transfer may require the assistance of one or more coworkers as well as the use of assistive patient handling equipment, such as a sliding board.” 2. During a review of the facility’s policy and procedure titled, “Resident Safety”, dated last revised 5/2022, the policy indicated, “It is the policy of [the facility] to ensure the optimum safety for all residents at all times…” During an observation on 7/22/25 at 7:30 AM, the resident shower rooms were observed for adherence to overall cleanliness and safety. Shower room [ROOM NUMBER] was observed to have an open container of new razors in an unlocked and open cabinet. Shower room [ROOM NUMBER] was observed to have multiple uncovered, used razors sticking out from the opening of an almost full sharp’s container easily accessible to residents, and an open container of new razors in an unlocked cabinet. During a concurrent observation and interview on 7/23/25 at 12:40 PM, with Licensed Nurse (LN) K in shower room [ROOM NUMBER] and 2, LN K agrees that open packages of new razors should not be left in an unlocked, nor open cabinet, and used, uncovered razors should not be left sticking out of a mostly full sharp’s container accessible to residents. During a concurrent observation and interview on 7/23/25 at 2:00 PM, with Assistant Director of Nursing (ADON) I, outside shower room [ROOM NUMBER], pictures of the shower rooms [ROOM NUMBERS] were observed. ADON I confirms that open packages of new razors should not be left in an unlocked, nor open cabinet, and used, uncovered razors should not be left sticking out of a mostly full sharp’s container accessible to residents. During a concurrent interview and picture review on 7/23/25 at 5:00 PM, with DON in the office the surveyors were utilizing, pictures of shower rooms [ROOM NUMBERS] were observed. DON confirmed that open packages of new razors should not be left in an unlocked, nor open cabinet, and used, uncovered razors should not be left sticking out of a mostly full sharp’s container accessible to residents. This is a matter of resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of two residents (Resident 1) sampled for falls was free from an avoidable fall. According to the facility's assessments, Resident 1 had difficulty maintaining an upright posture and poor safety awareness. Certified Nursing Assistant (CNA) B observed Resident 1 leaning over and reaching for the floor but did not help Resident 1 to a safe position and left Resident 1 unsupervised. Resident 1 had no post fall assessment and Resident 1's care plan did not provide interventions for what to do if Resident 1 was found on the floor unwitnessed. This fall resulted in Resident 1 falling and sustaining a broken left hip. Resident 1 required hospital admission for surgery. Resident 1 had a decline in her physical, social, and mental well-being due to increased pain. Findings: A review of the facility's policy, Resident Safety, dated 7/1/24, indicated, It is the policy of [name of facility] to ensure the optimum safety for all residents at all times by increasing staff awareness and encouraging strict adherence to practices that ensure optimum resident safety. A. Be alert for, and report promptly, any unsafe conditions or practices that you see. A review of Resident 1's undated admission Record indicated her admission to the facility on [DATE]. Her diagnoses included Dementia (loss of memory, language, problem-solving, and other thinking abilities), Parkinsonism (a condition causing tremors, slow movements, stiffness, and difficulty with balance), hearing loss, Osteoporosis (weak and brittle bones), and a traumatic brain injury (an injury to the brain caused by an external force, such as a blow, jolt, or impact to the head). A review of Resident 1's Quarterly Minimum Data Set (MDS, a data-driven resident clinical assessment), dated 2/8/25, indicated a score of 3 out of 15 on her Brief Interview for Mental Status (BIMS, an assessment of memory, thinking, and problem-solving that is scored from 0/worst to 15/best). This score indicated severe memory and decision-making problems. Resident 1 walked independently and could sit and stand with set up help (the helper assists the resident prior to, or after sitting or standing). A review of Resident 1's Fall Risk Evaluation, dated 1/28/25, indicated a score of 12, which was High Risk for falls. The Fall Risk Evaluation indicated the factors contributing to this risk included: sustaining 1 to 2 falls in the past three months, a balance problem while standing, disorientation to person, place, and time, and taking risperidone (an antipsychotic medication) that had potential adverse side effects of tremor, stiffness, restlessness, and involuntary movements. A review of Resident 1's At Risk for Falls care plan, revised on 4/6/25, indicated, [Resident 1] is [at] risk for falls r/t [related to] confusion, unaware of safety needs. Interventions included providing a safe environment, anticipating and meeting Resident 1's needs, providing activities to minimize falls, watching for signs of weakness and unstable gait (how a person walks), notifying the Physician (MD), and directing Resident 1 to a quiet area if she showed fatigue and sat or lay on the floor. During an interview on 5/2/25, at approximately 11:00 am, Housekeeper (HSK) A stated she observed Resident 1 fall from her chair onto her left side in the hallway. HSK A stated she heard a thud and ran to check for blood. HSK A stated she saw no staff in the hallway or at the nurse's station. HSK A stated she found Licensed Nurse (LN) C in the medication room and informed her of the fall. HSK A stated, Resident 1 was laying down on her left side and she never straightened her legs. HSK A stated, The nurse [LN C] said [to Resident 1] 'why you lay down on the floor this is not nice.' HSK A stated, I said [to LN C] she [Resident 1] did not lay down she fell. HSK A stated she witnessed Certified Nursing Assistant (CNA) B lift Resident 1 by placing her arms under Resident 1's armpits, and LN C push Resident 1 onto the chair with her knee. HSK A stated she heard Resident 1 cry and say, leave me alone it hurts. HSK A stated she informed LN C three times that Resident 1 had fallen. HSK A stated They (LN C and CNA B) did not assess her [Resident 1] or do vitals. HSK A stated that Resident 2 also witnessed the event. A review of Resident 2's undated admission Record indicated she was admitted to the facility on [DATE], with diagnoses including conduct disorder, dysphagia (difficulty swallowing), high blood pressure, and seizures. A review of Resident 2's Annual MDS dated [DATE] indicated a BIMS score of 14, signifying intact cognition (ability to think and reason). During an interview in Resident 2's room on 5/12/25, at 1:30 pm, Resident 2 stated, I saw lady [Resident 1's name] fall and I saw [LN C's name] and another person [unnamed] get her off the floor and she [Resident 1] said my leg, my back hurts then she spent the rest of the day in her room. Resident 2 stated, I saw her fall, I told [LN C's name] that she fell. During a telephone interview on 5/13/25, at 4:11 pm CNA B stated that on 5/2/25, around 11:00 am, just before Resident 1 was on the ground, she witnessed Resident 1 in a chair bending over, reaching for the ground like she was picking up something off of the floor. CNA B stated, I told her to sit up straight and told the nurse [LN C] at the desk that she was bending over then went into another resident's room [unknown]. CNA B indicated that Resident 1 would sit at the nurse's station for better supervision. CNA B stated, When I went by her and told her to sit up, I did not stop to make sure she was sitting up and in a safe position. CNA stated, I should have made sure she [Resident 1] was safe before I left her. When CNA B returned, Resident 1 was on the floor. CNA B stated that she and LN C picked Resident 1 up from the floor and placed her back in the chair. CNA B stated that Resident 1, who had walked earlier, was unable to bear any weight and said, it hurts! with a tight, uncomfortable expression. During an interview on 5/13/25, at 4:11 pm LN C stated that around 11:00 am on 5/2/25, she returned from the Medication Room to find Resident 1 on the floor. LN C stated Resident 1's care plan indicated she would sit herself on the floor. LN C stated, I did not know if she [Resident 1] fell or if she sat intentionally. LN C stated, I did not know if it was witnessed or unwitnessed. LN C stated she witnessed CNA B quickly lift Resident 1 by placing her arms under Resident 1's armpits. LN C stated, CNA B put Resident 1 on my knee then I pushed her onto the chair with my knee and hands. LN C stated she touched Resident 1's left shoulder and left hip, and Resident 1 was tense and pushed her away. LN C stated, [Resident 1] was rigid on the floor and was tense, so I did not move her extremities [assess range of motion of her arms and legs]. She would not move anything for me. I should have assessed her for a fall, but I did not. I gave her Tylenol because she said it hurt. LN C indicated that 20 minutes later, at lunchtime, Resident 1 stated, I do not want lunch. LN C stated that at noon, Resident 1 was wheeled to her room and stated, leave me alone and don't move me, but two staff members transferred her to her bed. LN C stated she did not notify the primary physician or Resident 1's responsible party at that time and should have. LN C stated she informed the Director of Nursing (DON) of the incident, and the DON told her that because Resident 1 had a care plan to sit on the ground, this was not considered a fall. LN C waited until the end of her shift on 5/2/25, at 5:33 pm to email MD. LN C stated she did not take vitals or assess Resident 1 while she was on the floor because Resident 1's care plan indicated she sat herself on the ground. LN C stated she did not see Resident 1 sit herself on the ground and did not remember anyone saying Resident 1 fell. LN C stated Resident 1 had pain, and she should have assessed Resident 1 and notified the MD at the time of the incident, but she did not. During an interview on 5/14/25, at 3:41 pm the Director of Nursing (DON) indicated that CNA B should have helped Resident 1 back into a safe sitting position before leaving her unsupervised, and she did not. The DON stated, There should have been an assessment when she (Resident 1) was on the floor and there was not. The DON stated that if staff found a resident on the floor and were unsure how it happened, they should consider it a fall. However, because Resident 1 had a care plan that said she sits herself on the ground, interventions to assess Resident 1 for a fall and injury did not happen. The DON stated, we did not follow our post fall policy, and we should have. A review of Resident 1's progress note titled Alert Note dated 5/2/25 LN F indicated on May 2, 2025, at 8:49 pm, When coming into this shift [I] received report from off going nurse [LN C] about resident [Resident 1] sitting on the floor, having pain in left leg and arm, [and] to monitor. Resident [1] was still c/o (complaining of) pain at 6:31 pm, this nurse gave Tylenol to resident c/o pain in left leg and arm. [Resident 1] refusing care and vital signs. The medication was ineffective at 7:10 pm. This nurse then informed Dr [MD's name] of these findings.Dr [MD's name] gave orders to this nurse to send resident out to ED (Emergency Department) for pain. A review of Resident 1's ED's CT (computed tomography- a computerized x-ray) scan of her left femur (large bone of the upper left leg) results, dated 5/2/25, at 9:52 pm, indicated Resident 1 had an Acute Displaced sub capital left femoral neck fracture (a broken left hip bone). During an interview at a Local Hospital (LH) with Resident 1's Hospital Occupational Therapist (OT) on 5/14/25, at 10:30 am Resident 1's Hospital Occupational Therapist (OT) indicated that Resident 1 came to LH's emergency department (ED) on 5/2/25 and was diagnosed with a broken left hip. The OT stated Resident 1 was then transferred to another hospital for surgery and then transferred back to LH. The OT stated Resident 1 was in significant pain and unwilling to participate in therapy and was taking OxyContin (a strong opioid [narcotic] pain medication used to relieve severe ongoing pain, which may lead to severe psychological or physical dependence and has abuse potential and can cause serious or life-threatening breathing problems and death) 5 mg (milligrams) for pain. During an interview with Resident 1's Hospital Nurse (HN) at the LH on 5/14/25, at 10:35 am, Resident 1's Hospital Nurse (HN) stated that Resident 1 was in significant pain and completely dependent on staff for assistance. The HN noted that OxyContin made Resident 1 very sleepy and foggy, so hospital staff were attempting to adjust her pain medication. During an observation and interview at LH on May 14, 2025, at 10:55 am, Resident 1 lay in bed with her right leg bent at the knee and her left leg flat. Resident 1 slightly moved her right leg but not her left. When asked how she was doing, Resident 1 replied, Not very good without opening her eyes. Resident 1's speech was weak and slow. She stated, I do not feel good. It hurts in different places. I cannot pinpoint it (where the pain was). Resident 1 never opened her eyes, smiled, or turned her head during the visit. Three hospital staff entered Resident 1's room to change her left hip dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 1) sampled for post-fall pain received the treatment and care to manage pain when: * Staff did not promptly assess Resident 1 for a change of condition for a new onset of pain in her left arm and left hip after she was found on the floor. Staff picked Resident 1 up off the ground and put her into a chair while she complained of pain. * Staff gave Resident 1 medication ordered for mild pain when she experienced moderate pain. * The Physician (MD) was not immediately notified of Resident 1's fall and complaint of pain with movement. These failures caused Resident 1 to experience moderate and severe left arm and left leg pain for eight hours, prevented her from eating lunch or dinner. Findings A review of the facility's policy, Change in Condition and Alert Charting, revised November 2024, indicated, A change in condition is defined as anytime an accident involving the resident results in injury which requires provider's intervention; there is a significant change in the resident's physical, mental, or psychosocial status or behavioral condition changes; or a need to alter treatment or add a new medication. The policy indicated, The following are some examples of adverse changes in resident condition: .Fall: witnessed or reported, .Any sudden and/or marked adverse change in signs/symptoms, or behavior exhibited by a resident The policy indicated, It is the policy of [name of facility] to promptly recognize any resident changes in condition and implement alert charting, and that The nurse will conduct an assessment and notify the resident's primary provider, resident representative and the resident. A review of the facility's policy, Pain Management in the Skilled Nursing Facility, revised November 2024, indicated, The goal of pain management is to minimize the amount, duration and intensity of pain The policy indicated, Residents will be assessed for the presence or absence of pain during the initial assessment and periodically thereafter. If pain is present at any initial assessment or following a pain producing event, it will be managed in accordance with this policy. The policy indicated, Pain level will be reassessed within 30-60 minutes after each pain management intervention with the post intervention pain rating documented on the Medication Administration Record (MAR). The policy indicated, Pharmacological (pertaining to medication) Management. a. Pain medication shall be administered utilizing the appropriate dosage as indicated by the provider's medication order and the 10-point Pain Scale: mild pain 0-3, moderate pain 4-7, severe pain 8-10. The policy indicated, Non-pharmacological (treatments other than medication) techniques will be used as appropriate and may include but not be limited to: Repositioning of the resident The policy indicated, Collaborate with the provider as needed regarding use of adjuvant medications (the use of other medications to aid in pain relief) The policy indicated, Initial pain assessments, b. Medication administration, c. Evaluation of the effectiveness of pain management interventions. D. Reportable conditions or adverse reactions on the appropriate event for and in the record. A review of the facility's policy, Fall Prevention and Post Fall Guidelines, revised September 2024, indicated a Post Fall Protocol that included, Perform an initial assessment immediately: 1. Vital signs (a group of the four to six most crucial medical signs that indicate the status of the body's vital functions) . 2. Initial Neuro Assessment (assessment of sensory and motor responses, especially reflexes, to determine whether the nervous system is impaired) . d. mobility (movement of extremities .). 3. Obvious injuries (e.g., . new pain with movement or palpation). C. Contact the physician immediately so that he/she can reassess the patient. A review of Resident 1's undated admission Record indicate she was admitted to the facility on [DATE], with diagnoses including Dementia (loss of memory, language, problem-solving and other thinking abilities), parkinsonism (a syndrome characterized by tremors, bradykinesia [slowness of movement], rigidity (stiffness), and postural instability [difficulty maintaining an upright posture and balance]), hearing loss, osteoporosis (weak and brittle bones), and traumatic brain injury (an injury to the brain caused by an external force, such as a blow, jolt, or impact to the head). Resident 1 had a responsible party (RP) who made health care decisions for her. A review of Resident 1's Quarterly Minimum Data Set (MDS- a standardized resident assessment) dated 2/28/25, indicated a Brief Interview for Mental Status (BIMS- a numerical representation of a person's ability to think and reason, assessed through a structured interview) score of 03, signifying severe cognitive impairment. Section GG (a standardized assessment used to evaluate a patient's self-care and mobility abilities) indicated that Resident 1 walked independently and could sit and stand with set-up help. During an interview on 5/12/25, at 11:02 am, the Assistant Director of Nursing (ADON) confirmed Resident 1 fell on 5/2/25, around 11:15 am. A review of Resident 1's progress note titled Alert Note dated 5/2/25, at 4:51 pm (5.5 hours after the incident), Licensed Nurse (LN) C documented on alert charting for left leg pain. resident (Resident 1) sat on the floor with no initial c/o (complaint) of pain. One hour later she stated pain, ACETAMINOPHEN ( Tylenol) was given and effective. Re-eval 5/5/25. A review of Resident 1's progress note titled Alert Note dated 5/2/25, at 8:49 pm, LN F documented, When coming into this shift (I) received report from off going nurse (LN C) about resident (Resident 1) sitting on the floor, having pain in left leg and arm, (and) to monitor. Resident (Resident 1) was still c/o (complaining of) pain at 6:31 pm, this nurse gave Acetaminophen to resident c/o pain in left leg and arm. (Resident 1) Refusing care and vital signs. The medication was ineffective at 7:10 pm. This nurse then informed Dr (MD's name) of these findings.Dr (MD's name) gave orders to this nurse to send resident out to ED (Emergency Department) for pain. A review of Resident 1's ED CT (computerized x-ray) scan of her left femur results, dated 5/2/25, at 9:52 pm, indicated an Acute Displaced sub capital left femoral neck fracture (a broken left hip bone). During an interview on 5/12/25, at 12:35 pm, Housekeeper (HSK) A stated that on 5/2/25, at approximately 11:00 am, she observed Resident 1 fall onto her left side in the hallway near the nurse's station. HSK A stated she heard a thud and ran to check for blood. HSK A stated she observed no staff in the hallway or at the nurse's station. HSK A stated she found LN C in the medication room, knocked on the door, and informed LN C that Resident 1 fell. HSK A stated, Resident 1 was laying down on her left side and she never straightened her legs. HSK A stated, The nurse (LN C) said (to Resident 1) 'why you lay down on the floor this is not nice.' HSK A replied, I said (to LN C) she (Resident 1) did not lay down she fell. HSK A witnessed Certified Nursing Assistant (CNA) B lift Resident 1 by placing her arms under Resident 1's armpits, and LN C push Resident 1 onto the chair with her knee. HSK A heard Resident 1 cry and say, leave me alone it hurts. HSK A informed LN C three times that Resident 1 had fallen. HSK A also noted that Resident 2 witnessed the event. A review of Resident 2's undated admission Record indicated she was admitted to the facility on [DATE], with diagnoses including conduct disorder, dysphagia (difficulty swallowing), high blood pressure, and seizures. Resident 2's annual MDS dated [DATE] indicated a BIMS score of 14, signifying intact cognition. During an interview in Resident 2's room on 5/12/25, at 1:30 pm, Resident 2 stated, I saw lady (Resident 1's name) fall and I saw (LN C's name) and another person (unnamed) get her off the floor and she (Resident 1) said my leg, my back hurts then she spent the rest of the day in her room. Resident 2 stated, I saw (Resident 1) fall, I told (LN) that she fell. Resident 2 stated, They (LN C and another person) picked her up and put her in a regular chair and then later they transferred her to a wheelchair and took her to her room. Resident 2 stated she heard Resident 1 say, let me go lay down I'm in pain; I want to lay down. Resident 2 stated, When she (Resident 1) was sitting in the chair I was rubbing her back because she kept saying 'it hurts.' During a phone interview on 5/13/25, at 4:00 pm, CNA B stated that on 5/2/25, around 11:00 am, she saw Resident 1 on the floor after returning from answering a call-light. CNA B and LN C picked Resident 1 up from the floor and placed her back in the chair. CNA B stated that Resident 1, who had walked earlier, was unable to bear any weight and said, it hurts! with a tight, uncomfortable expression. CNA B stated, I did not take her vitals. You're supposed to make sure she (Resident 1) is ok (before moving a resident), but I do not know if that happened. CNA B stated, around noon (Resident 1) was unable to walk because of the pain so we (LN C and CNA B) helped her lay down on the bed and she (Resident 1) was saying it hurt but she was not specific to where the pain was. CNA B stated, LN C and I tried to move her (Resident 1) in the bed and that's when she was saying it hurts, it hurts. During an interview on 5/13/25, at 4:11 pm, LN C stated that on 5/2/25, around 11:00 am, she returned from the Medication Room to find Resident 1 on the floor. LN C stated that Resident 1's At Risk For Falls care plan indicated she would sit herself on the floor. LN C stated, I did not know if she (Resident 1) fell or if she sat intentionally. LN C stated, I did not know if it was witnessed or unwitnessed. LN C stated she witnessed CNA B quickly lift Resident 1 by placing her arms under Resident 1's armpits. LN C stated, CNA B put Resident 1 on my knee then I pushed her onto the chair with my knee and hands. LN C stated she touched Resident 1's left shoulder and left hip, and Resident 1 was tense and pushed her away. LN C stated, (Resident 1) was rigid on the floor and was tense so I did not move her extremities (assess range of motion of her arms and legs). She would not move anything for me. I should have assessed her. I gave her [Acetaminophen] because she said it hurt. LN C stated that 20 minutes later, at lunchtime, Resident 1 stated, I do not want lunch. LN C stated that at noon, Resident 1 was wheeled to her room and stated, leave me alone and don't move me, but two staff members transferred her to her bed. LN C stated she did not notify the primary physician or Resident 1's responsible party at that time and should have. LN C stated she informed the DON of the incident, and the DON told her that because Resident 1 had a care plan to sit on the ground, this was not considered a fall. LN C stated she waited until the end of her shift on 5/2/25, at 5:33 pm (6 hours after the incident), to email the Physician (MD). LN C stated she did not take vitals or assess Resident 1 while she was on the floor because Resident 1's care plan indicated she sat herself on the ground. LN C stated she did not see Resident 1 sit herself on the ground and did not remember anyone saying Resident 1 fell. LN C stated Resident 1 had pain, and she should have assessed Resident 1 and notified the MD at the time of the incident, but she did not. During an interview on 5/14/25, at 1:29 pm, HSK D stated that on 5/2/25, around 11:00 am, she saw Resident 1 lying on the floor on her left side. HSK D stated she heard HSK A tell LN C that Resident 1 had fallen. HSK D stated she observed LN C and CNA B pick up Resident 1 and place her in the chair, and Resident 1 screamed that it hurt. HSK D stated that around noon, she saw the DON and LN C trying to help Resident 1 stand up, and Resident 1 resisted, saying, It is hurting. During an interview on 5/14/25, at 1:42 pm, CNA E, stated she was assigned to care for Resident 1 on 5/2/25. CNA E stated that around 12:00 pm, Resident 1 and Resident 2 were sitting in a chair at the nurse's station with LN C and the DON also present. CNA E stated, Resident 2 said 'she (Resident 1) fell, she fell.' CNA E stated she observed Resident 1 sitting in a chair with her legs curled up to the left. CNA E stated Resident 1 was not her normal self, not smiling, engaging, or looking back. CNA E stated she attempted to help Resident 1 walk to her room, which usually worked, but Resident 1 would not. CNA E stated she, LN C, and the DON tried to help Resident 1 stand up and transfer her to a wheelchair. CNA E stated, She (Resident 1) was holding her left hip. She was making moaning noises We (DON, LN C, and CNA E) then transferred Resident 1 to her bed, and she was moaning, and she said no, no, no. CNA E stated, When she (Resident 1) was in bed she had her legs curled up and was leaning to the right. The DON felt (Resident 1's name) left leg but we did not move her. Resident 1 did not want her legs straightened so we supported her back and left her lying there and she was moaning. She was saying no.no. no. CNA E added, At 2:00 pm she was still moaning and said the hip hurt and was still in the same position. I informed LN C, and she said they gave her (Resident 1) Acetaminophen. CNA E stated she felt Resident 1 was in more pain at 2:00 pm. CNA E continued to say that at 4:00 pm, she (CNA E) tried to get Resident 1 up for dinner, but she (Resident 1) was still curled up in the same position and she was holding her left hip, was moaning and did not eat lunch or dinner that day. During an interview at a Local Hospital (LH) with Resident 1's Hospital Occupational Therapist (OT) on 5/14/25, at 10:30 am, the OT stated that Resident 1 arrived at LH's emergency department (ED) on 5/2/25 and was diagnosed with a broken left hip. The OT stated that Resident 1 was then transferred to another hospital for surgery and subsequently returned to LH. The OT stated Resident 1 was in significant pain and unwilling to participate in therapy, taking OxyContin (a strong narcotic pain medication used to relieve severe ongoing pain, which may lead to severe psychological or physical dependence and has abuse potential and can cause serious or life-threatening breathing problems and death) 5 milligrams (mg-a unit of measure) for pain. During an interview with Resident 1's Hospital Nurse (HN) at the LH on 5/14/25, at 10:35 am, HN stated that Resident 1 was in significant pain and completely dependent on staff for assistance. HN stated that OxyContin made Resident 1 very sleepy and foggy, so hospital staff were attempting to adjust her pain medication. During an observation and interview on 5/14/25, at 10:55 am, Resident 1 lay in bed at LH with her right leg bent at the knee and her left leg flat. Resident 1 slightly moved her right leg but not her left. When asked how she was doing, Resident 1 stated, Not very good without opening her eyes. Resident 1's speech was weak and slow. Resident 1 stated, I do not feel good It hurts in different places I cannot pinpoint it (where the pain was). Resident 1 never opened her eyes, smiled, or turned her head during the visit. A review of Resident 1's Amount Eaten record for 5/2/25, indicated she did not eat lunch or dinner on that day. A review of Resident 1's Physician orders dated May 2025, indicated an order for Acetaminophen Tablet 325 mg (two tablets by mouth every six hours as needed for mild pain rating of 1-3), written on 10/25/24, by the MD. Physician orders for 5/2/25, contained no other physician orders for moderate pain levels (4-7) or severe pain levels (8-10). A review of Resident 1's May 2025 Medication Administration Record (MAR) indicated that on 5/2/25, at 12:00 pm, LN C administered Acetaminophen tablet 325 mg, ordered for mild pain (1-3), two tablets for Resident 1's pain level of six (moderate pain). On 5/2/25, at 6:30 pm, LN F administered another Acetaminophen tablet 325 mg, two tablets, for Resident 1's pain level of seven (moderate pain). During a concurrent phone interview and review of Teams messages on 5/14/25, at 11:12 pm, the MD stated that on 5/2/25, at 5:33 pm (6 hours after the incident), he received a Teams message from LN C that read, [Resident 1] sat herself on the ground and had pain one hour after that and that Acetaminophen helped. The MD stated he received another Teams message on 5/2/25, at 7:10 pm (8 hours after the incident), from LN F, which stated, [Resident 1] has been in pain, I administered Acetaminophen at 6:31(pm) when she complained of 7/10 (moderate) pain. [Resident 1] c/o (complained of) pain in left arm and left leg. The medication is ineffective, [Resident 1's] pain has increased 9/10 (severe), she has been lying in bed on her right side (7 hours since placed in bed). She is in so much pain, staff and I are unable to touch her or obtain VS (vital signs) or to get an assessment she cries out when we attempt care. [Resident 1] didn't touch her dinner tray and refused ensure. The MD stated that after the second Teams message, he immediately called the nurse and had [Resident 1] sent to the ED. The MD stated, Later I found out that a fall (by Resident 1) was witnessed by the housekeeper. There was a lack of documentation about this. The (first) message was misleading. The nurse did not convey that it happened hours before (the 5:33 pm Teams message). She (LN C) indicated that she knew that [Resident 1] intentionally sat on the floor. I had no indication that [Resident 1] had a fall. If the nurse did not witness the incident, then she should have indicated that. If there was pain, then a fall assessment should have been done. If there was pain with movement then they (staff) should not have gotten [Resident 1] up. The MD indicated that if he had been notified right away of the situation, this would have minimized the time [Resident 1] was in pain. During an interview with the DON and record review on 5/14/25, at 3:41 pm, the DON reviewed Resident 1's May 2025 MAR, physician orders, and nurses' progress notes. The DON stated [Resident 1] should have been assessed for a fall when she was on the floor, and the physician should have been promptly notified of [Resident 1's] pain but was not. A review of Resident 1's MAR and physician orders for 5/2/25, indicated that Resident 1 had a pain level of six and seven and received Acetaminophen, which was not ordered for pain above a level of three, and the MD should have been notified to obtain an order for appropriate pain medication, but was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up on an identified pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence, where bones are close to the surface of the skin), to evaluate, and intervene in a timely manner to prevent an avoidable pressure ulcer for one of three residents (Resident 1) sampled for pressure ulcers. This resulted in Resident 1 developing a 1-centimeter (cm) x 1.25 cm pressure ulcer on her left heel. Findings: During a review of National Pressure Injury Advisory Panel (a global driver of quality improvement and patient safety in health care) website newsletters titled, Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, updated 2/25/25, indicated: · A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. · Stage 1 Pressure Injury: Non-blanchable erythema of intact skin - Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. · Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis - Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent as an intact or ruptured serum-filled blister. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. · Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration - Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. · Pressure injury prevention and treatment requires multi-disciplinary collaborations, good organizational culture and operational practices that promote safety. Per the International Guideline, risk assessment is a central component of clinical practice and a necessary first step aimed at identifying individuals who are susceptible to pressure injuries. · Other interventions that influence an individual's healing process may include identifying nutritional needs, repositioning and early mobilization, skin care, use of support surfaces, cleansing and debridement, pain assessment and management, psychological and spiritual support, and family support. · Skin care - Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen: Inspect the skin upon admission and at least daily for signs of pressure injuries; Assess pressure points, temperature, and the skin beneath medical devices; Clean the skin promptly after episodes of incontinence, use skin cleansers that are pH balanced for the skin, and use skin moisturizers; Avoid positioning the patient on an area of pressure injury. · Positioning and Mobilization - Turn and reposition at-risk patients, if not contraindicated; Plan a scheduled frequency of turning and repositioning the patient; Consider using pressure-relieving devices when placing patients on any support surface; Consider the patient's body size, level of immobility, exposure to shear, skin moisture and perfusion when choosing a support surface. During a review of Resident 1's medical record, indicated that Resident 1 was admitted to the Loyalton campus on 9/23/24 with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) without behavioral disturbance, personal history of (healed) traumatic fracture. Resident 1 was transferred to the facility's Portola Campus on 1/30/25. Resident 1 was not her own healthcare decision maker. During a review of Resident 1's admission Minimum Data Set (MDS - an assessment and care screening tool), dated 10/3/24, in the section M - Skin conditions, the MDS indicated that Resident 1 did not have a pressure ulcer/injury, a scar over bony prominence, or unhealed pressure ulcers/injuries. During a review of Resident 1's most recent MDS, dated [DATE], indicated that Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 out of 15, indicating her cognition (ability to think and reason) was severely impaired. During a review of Resident 1's most recent MDS, dated [DATE], section GG (a section which stands for Functional Abilities and Goals; it specifically assesses a patient's ability to perform self-care tasks and mobility activities, including their admission performance, discharge goals, and how much assistance they require for these functions), indicated that Resident 1 needed maximal assistance (the staff does more than half the effort) from the staff for her mobility (the ability to move or be moved freely and easily). During a concurrent interview and review of Resident 1's medical record with the Director of Nursing (DON) A on 2/11/25 at 1:39 pm, DON A stated that she did not know when Resident 1 started developing the pressure injury on the left heel. DON A confirmed that Resident 1's progress note, dated 12/6/24 at 6:36 pm, written by Licensed Nurse (LN) D, indicated that LN D wrote She [Resident 1] had an old area on her left heel. We are going to watch the area and make sure we float her feels when she is in the bed. DON A confirmed that LN D initiated a care plan on 12/6/25 for Resident 1's left heel lesion, the plan indicated, Left heel has a hard black callous, and the interventions were to, Float her heels while she is in the bed; monitor for signs of infection; notify the MD if becoming infected or becomes open; perform any treatments that are ordered by medical provider; use the booties for her feet while she is in the bed. The DON A confirmed that there was no record indicating that the staff were floating the Resident1 's heel and applied the booties as indicated on the care plan. DON A confirmed that the Care Conference, held on 1/8/25 at 9:44 am, in the section of Nursing Summary, indicated that Resident 1's Responsible Party (RP) Was concerned over her [Resident 1] decline She [Resident 1] also has a pressure injury to her left heel. She doesn't like to converse much anymore. She requires more care and participates less in her cares DON A also confirmed that there was no plan/intervention initiated to treat Resident 1's pressure injury after the meeting. DON A confirmed that the Care Conference, held on 1/22/25 at 12:02 pm, in the section of Nursing Summary, indicated that the family Expressed concern about a sore on her [Resident 1] left heel . DON A confirmed that the physician was then notified, and wound care order was obtained on 1/22/25 after this care conference. A delay of 47 days after the wound was identified by LN D on 12/6/24. During an interview on 3/6/25 at 2:11 pm, Family Member (FM) C confirmed that Resident 1 did not have any skin lesion before Resident 1 was admitted to the facility. The FM C stated, I wanted to say I found that sore two weeks before she [Resident 1] was transferred to another facility, right around Christmas. It was always wrapped with bandage. I had asked before when I came in, and she was not wearing her shoes, no shocks. They said, 'Ya, that happened'. During a concurrent interview and record review on 3/10/25 at 9:45 am with the MDS Registered Nurse (MDS RN), the MDS RN confirmed that Resident 1's MDS, dated [DATE], completed by RN G, in the section M -Skin, the MDS indicated that Resident 1 was not at risk of developing pressure ulcers/injuries. The MDS RN stated, I did not do Resident 1's admission MDS. RN G who did it was retired. MDS RN stated that Resident 1 was clearly at risk of developing pressure ulcer, and she did not have an answer as to why RN G marked it as No. MDS RN also stated that Once a resident was marked as at risk of developing pressure ulcer in MDS, the pressure ulcer prevention care plan would be initiated. The MDS RN confirmed the Resident 1 did not have pressure ulcer prevention care plan developed when she was admitted . During a concurrent interview and record review on 3/10/25 at 10 am with DON A, Resident 1's record was reviewed. DON A confirmed that there was a discrepancy in which RN G marked Resident 1 was not at risk of developing pressure injury in Resident 1's MDS, dated [DATE], but RN G assessed Resident 1 with a score of 18 at BRADEN Scale for Predicting Pressure Ulcer Risk (a tool used to assess a patient's risk of developing pressure injuries), dated 10/15/24, indicating Resident 1 was at risk for developing pressure ulcers. During a concurrent interview and record review on 3/10/25 at 10:45 am, with DON A, and LN D. LN D recalled that Resident 1 did not have any skin issue when she assessed Resident 1 during admission assessment on 9/23/24. The LN D stated, When Resident 1 had a bowel movement on 12/6/24, I assisted the Certified Nursing Assistant (CNA) to clean up Resident 1. The CNA told me, 'Did you see that?' I then saw a black, and dry blister about the size of 2 cm X 2 cm on Resident 1's left heel. I talked to the RP and reported it to the DON A, the DON A said, 'document it', so I did, and care planned it. I did not report it to the physician because it was dry. The LN D confirmed that Resident 1's care plan indicated, floating feet, however, there was no floating feet task initiated to indicate the staff was providing such service to Resident 1. LN D stated, We just started PCC (a software platform used to manage and streamline various aspects of facility operations, including resident care, documentation, and billing) in September 2024. No one was checking whether Resident 1's feet were floated or not. The DON A agreed and said, we should have better communication on the wound care. During a concurrent interview and record review on 3/10/25 at 12:14 pm, with DON A, LN D and LN E, a facility's document titled, Alert Charting - for changes in condition, dated 12/2024, was reviewed. Resident 1's name appeared on the record, dated 12/6/24, the reason for Resident 1 on alert charting was blackened area on L heel highlighted in yellow. Both LN D and E stated that this Alert Charting was how the nursing staff documented the wound care/condition and gave report to the next shift. They admitted that they did not document/update the wound condition in the resident's progress note, or weekly skin assessment. Both LNs agreed that there was no wound assessment on the alert chart, and there was no way to know Resident 1's wound condition such as the stage, the size, the color, any discharge, etc. since the nursing staff did not document it anywhere else. The LN E stated, I was never told that I have to document the wound condition in the weekly skin assessment. The DON A stated the facility did not have skin assessment, wound care, or pressure ulcer policy because the facility did not have wound care nurse, and did not provide wound care training even though the facility had been providing wound care service to the residents, the DON A said, We don't need it, we just looked it up online. The DON A stated that someone cancelled Resident 1's alert charting on 12/9/24 and highlighted it in yellow. She said, When an alert charting - change condition was resolved, we highlighted it to indicate that it's resolved. I believe that was why Resident 1's pressure sore was missed. We did not know who marked it, but it's too late now! During a concurrent interview and record review on 3/10/25 at 2:31 pm with DON B, in the Portola campus, Resident 1's admission progress note was reviewed. DON B stated Resident 1 was transferred from the Loyalton campus to her facility (Portola campus) on 1/30/25, she said, Resident 1 came with a pressure ulcer on her left heel, it was measured 1 cm X 1.25 cm. DON B stated, We have a wound management policy. The Loyalton and Portola campuses are both distinct part skilled nursing facilities of the same hospital, so we [Loyalton Campus and Portola campus] share the same policy. DON B confirmed that the Wound Management policy, revised 2/2022, indicated: · It is the policy of the facility to follow guidelines for the preservation of skin, prevention of skin disruption and the identification, assessment, appropriate treatment and documentation of injuries to the skin including, but limited to, wounds. · Assessment should: be done and documented daily .; should include alteration or disruptions of the skin, paying special attention to bony prominences and areas of increased moisture, pressure of sheering; include a skin risk assessment by using the Braden Scale Assessment in admission assessment or shift assessment in the electronic medical record. · Documentation should include wound base; wound drainage; wound odor, wound edges; pain; edema; pulses; staging of wound (only if the wound has been determined to be caused by pressure) - refer to Medline Wound and Skin Care Reference Guide in Wound Care to stage wound. · Interventions - wounds should be managed as soon as they are identified. Notify the overseeing provider. Contact Physical Therapy or a Certified Wound Nurse for a consultation, if available and as directed by the overseeing provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent accidents for one of three sampled residents (Resident 3) when the resident's lower legs were not secured to a mechanical lift (a device used to lift and transfer residents) and the resident began to slip off the lift. Staff lowered the lift to the floor which caused Resident 3 to suffer broken bones in both legs. Findings: Review of Resident 3's admission record indicated she was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a chronic disease of the central nervous system that affected movement, thought, and mood), dementia (a mental disorder that caused memory loss and confusion), and generalized muscle weakness. Review of Resident 3' Physician's orders for the month of 12/2022, indicated an order dated 3/5/20, that Resident 3 was not capable of making her own healthcare decisions and was dependent on a wheelchair for mobility. Review of Resident 3's Minimum Data Set (a standardized resident assessment), dated 12/8/22, showed Resident 3 had severe cognitive impairment (loss of intellectual function). Resident 3 required assistance with transfers and eating and could not walk. A manual from ARJO Medical AB Limited, titled, [NAME] 3000: Operating and Product Care Instructions, dated 2/1/2004, was reviewed. [NAME] was the name of the sit-to stand mechanical lift used to transfer Resident 3 from the chair to the bed. The manual listed steps for using the lift with the Standing Sling. The sling was placed around the resident's lower back so that the bottom of the sling lied horizontally about two inches above the resident's waist with their arms outside the sling. Staff were to ensure the support strap was brought loosely around the body and fastened securely by pressing the buckles together. Once the sling had been fitted, the [NAME] 3000 was brought toward the front of the resident, facing the resident. When the resident was ready, staff were to assist or allow the resident to place their feet on the foot support and carefully push the [NAME] 3000 closer toward the resident to make full lower leg contact with the knee support. The manual cautioned that an assessment would have been needed to determine whether the resident required the lower leg straps. Staff were to apply the lower legs straps if necessary. The manual cautioned that the resident's feet should always have remained in full contact with the foot support. When lifting, staff were instructed to check to ensure that the resident's feet did not lift from the support or floor. If this happened inadvertently, staff were instructed to lower the resident immediately until full foot contact with the support or floor was achieved. During a concurrent interview and observation, on 12/19/22, at 2:55 pm, the Assistant Director of Nursing (ADON) and Certified Nursing Assistant (CNA) A demonstrated use of the Sara lift on themselves as they would have done when moving residents from a seated to a standing position. ADON stated that use of this lift did not require two CNAs. A Nurses Note from Resident 3's record, dated 12/9/22, at 8:30 pm, by CNA B, was reviewed. The note read, When attempting to put resident to bed using [NAME] lyft [sic], resident wouldn't let me put straps on keeping her legs closed tight together, so I hurried to put her on her bed, and she moved legs off [NAME] lyft. So, I attempted to put her back in her chair and to try again and she wouldn't cooperate so lowered her safely to ground and called for help. A review of radiologic (medical imaging) images of Resident 3's knees, done on 12/10/22, showed a rod with screws in the left thigh bone and an artificial knee joint in the right knee from prior surgeries. A Radiology Report from Resident 3's record for bilateral (both sides) knee x-rays, dated 12/10/22, at 9:31 am, by the Radiologist, was reviewed. The report indicated that Resident 3's right knee had a comminuted (broken into small pieces) distal right femur (bottom of the thigh bone) fracture with posterior angulation (backward displacement). The report also listed osteopenia (loss of bone mass). The report indicated Resident 3's left knee had comminuted proximal left tibia and fibular (top of both lower leg bones) fractures. During an interview, on 12/19/22, at 4:05 pm, the Director of Nursing stated lifts were a nursing decision and the facility didn't get physician orders for specific lifts. During a telephone interview, on 2/2/23, at 4:44 pm, CNA B described the incident that occurred on 12/9/22. When attempting to transfer Resident 3 into bed, the resident stated, no, no, no and held her knees together which prevented applying the leg straps. When CNA B raised the lift, Resident 3 bent her knees backward and began to slide off the lift. CNA B couldn't leave Resident 3 hanging, so she lowered the device all the way to the floor and called for help.