**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to promote and maintain resident dignity for two (#35 and #51) of three residents reviewed out of 49 sample residents by providing care in a dignified, respectful and individualized manner. Specifically, the facility failed to: -Ensure Resident #35 was provided meal assistance in a dignified manner; and, -Ensure Resident #51 was treated with dignity and respect when asking for assistance. Findings include: I. Facility policy The Dignity policy, revised February 2021, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:44 p.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. II. Resident #35 A. Resident status Resident #35, age less than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing) following cerebral infarction, bipolar disorder, post-traumatic stress disorder and ataxia (neurological disorder causing lack of coordination and tremors). The 7/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up assistance for eating and substantial assistance for personal hygiene and dressing. B. Resident observations and interview On 7/28/24 at 5:49 p.m. certified nurse aide (CNA) #3 was observed assisting Resident #35 with her supper. Resident #35 was sitting in her wheelchair while CNA #3 stood beside the resident preparing her tray and assisting her with eating. Resident #35 was interviewed on 7/30/24 at 8:57 a.m. Resident #35 said sometimes the facility staff sat down when they assisted her with meals, but she said they primarily stood over her. Resident #35 said she preferred when the staff would sit down to assist her with eating. She said there was a folding chair in her room for the staff to sit in when they assisted her. On 7/30/24 at 12:31 p.m. the occupational therapist (OT) was assisting Resident #35 with lunch. The OT stood over the resident, cutting up her food and provided the resident with cueing. The resident had difficulty feeding herself due to tremors (uncontrolled muscle contractions causing shakiness) in her hands. -A folding chair was observed in the room, folded up by the dresser, however, the OT did not attempt to use the chair. On 7/31/24 at 8:34 a.m. CNA #4 was delivering breakfast to Resident #35. CNA #4 did not set up the tray for Resident #35 and started assisting the resident's roommate with eating. Resident #35 attempted to feed herself but was dropping eggs onto her lap due to her hand tremors. Resident #35 told CNA #4 she was frustrated and asked for help. When CNA #4 was finished assisting the resident's roommate, she went over and stood beside Resident #35 and assisted her with eating her breakfast. -A folding chair was observed in the room by the dresser, however, CNA #4 did not attempt to use the chair. Resident #35 was interviewed on 7/31/24 11:12 a.m. Resident #35 said when the facility staff stood when providing her assistance with eating, she felt belittled. Resident #35 said she was belittled her whole life and she would feel better if staff sat down on her level when they were assisting her with eating. C. Record review The self-care care plan, updated 7/30/24, documented Resident #35 fed herself with the use of a scoop lipped plate, black handled weighted utensils and a two handled mug with spouted lid. The 7/9/24 provider visit note documented Resident #35 reported her tremors remained impactful to her life and she had difficulty holding objects. The resident had requested to see a neurologist for worsening tremors and some further testing. The July 2024 CPO documented the resident received the following medication: Propranolol 10 mg (milligrams) three times a day for dystonic tremor (caused by involuntary muscle contractions), ordered on 6/10/24. D. Staff interviews The OT was interviewed on 7/30/24 at 12:34 p.m. The OT said she was trying a new scoop plate and weighted silverware with Resident #35. The OT said Resident #35 still needed help with eating some foods due to her tremors. CNA #4 was interviewed on 7/31/24 at 11:55 a.m. CNA #4 said she was taught to let residents try to eat on their own and only assist if they asked for help. CNA #4 said when assisting in the dining room, she sat down with the resident but she stood when assisting Resident #35 because there was not a chair in the room. She said she did not see the folding chair in Resident #35's room. The director of nursing (DON) was interviewed on 7/31/24 at 3:07 p.m. The DON said when staff assisted residents with eating, they should sit down to ensure they were not standing over the resident and providing a dignified dining experience. She said staff should sit down when assisting Resident #35 with meals. III. Resident #51 A. Resident status Resident #51, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2024 CPO, diagnoses included hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke - disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting the left non-dominant side. The 6/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required setup assistance with all activities of daily living (ADL). B. Resident interview Resident #51 was interviewed on 7/29/24 at 10:11 a.m. Resident #51 said the facility staff were rude at times. He said, for example, he had pushed his call light and asked licensed practical nurse (LPN) #5 to assist him with putting the blanket over the bottom of his feet. He said LPN #5 refused to help him and told him he was able to do it himself and she would stand there and watch. Resident #51 said he did not understand why LPN #5 could not just help him with the blanket instead of being rude. He said he was blamed for being rude to the facility staff but it was often a reaction to how he was treated by the staff. C. Record review The 7/8/24 nursing progress note, documented by LPN #5, revealed Resident #51 activated his call light and asked LPN #5 to cover his feet with the blanket. LPN #5 documented she told the resident that he could actually put the blanket over his feet on his own and there was no need to call anybody to do that for him. Resident #51 responded he could do it himself but he chose not to. The progress note documented LPN #5 educated Resident #51 and told him she would observe the resident putting the blanket over his feet independently. LPN #5 documented she told the resident he had to help himself if he wanted to get well. D. Staff interviews The NHA was interviewed on 7/31/24 at 3:04 p.m. The NHA said all residents should be treated with dignity and respect. She said all residents should be assisted if they asked for help, whether or not they were independent. The NHA said she read the progress note documented by LPN #5 on 7/29/24. She said LPN #5 should have assisted Resident #51 to cover his legs with the blanket. She said there was no need for LPN #5 to be rude to Resident #51. She said the facility staff should be helpful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#50) of one out of 32 sample residents received care consistent with professional standards of practice, to prevent the development of pressure ulcers, and to promote healing of pressure injuries. The facility's failure to provide necessary interventions to prevent Resident #50 from developing pressure ulcers, promote healing of the pressure ulcers and prevent worsening of the pressure ulcers. The resident was a significant risk for the development of pressure ulcers based on her compromised health, being treated for current pressure ulcers, and her being dependent on staff for activities of daily living. Due to the facility's failures, the resident developed a facility acquired unstageable pressure ulcer to the sacrum at the lower end of the spine (diagnosed 11/10/21), and facility acquired right heel stage 3 pressure ulcer (duration 9/9/2020). Furthermore, the nurse failed to follow the physician's wound care orders during the observed wound care. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP) Stages, last updated 2016, retrieved on 11/23/21 from: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed the following pertinent information: Pressure Injury: A pressure injury is localized damage to the skin and 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. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis . Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.`` II. Facility policy and procedure The Wound Care policy and procedure was requested from the nursing home administrator on 11/18/21 at 11:50 a.m. However, it was not provided during or after the survey. III. Resident #50 A. Resident status Resident #50, age [AGE], was initially admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included severe protein-calorie malnutrition, chronic pain syndrome, and paraplegia (paralysis of the legs and lower body). The 9/24/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance with two persons for bed mobility, transfers, dressing, bathing, and toilet use. Supervision and one person assistance required for personal hygiene. She reported symptoms of feeling tired or having little energy several days per week. No behaviors or rejection of care. Per the MDS the resident had no pressure ulcers upon admission. She was at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers/injuries at the time of this assessment. The resident had one unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar. B. Resident observations (cross-reference F880 for infection control measures) LPN #1 was observed on 11/17/21 at 10:11 a.m. as she performed Resident #50's wound care. The resident was lying flat on her back in bed putting pressure directly on the lower back and sacral wound. (per the resident's care plan the residents was to be positioned to offload pressure risk areas ). There was a low air loss mattress on the bed however, during the physician interview (see below, the wound doctor said the resident would benefit from a different mattress, an alternating air mattress). LPN #1 entered the room to complete the resident's wound care. The right foot gauze was stuck on foot wound, the date was not readable on the tape, LPN #1 continued the treatment with soiled gloves. The size of the right heel wound was approximately 3.3 cm length x 3.3 cm width (approximately half a dollar size) with black eschar and slough present around the wound. LPN #1 cleaned wounds with wound cleaner, and used the same gloves to apply the medihoney treatment which she squirted on the wound. Then LPN #1 wrapped up the ankle with gauze. LPN #1 helped Resident #50 roll to the left side. The resident lower back at the sacral area had a wound approximately 4 cm length x 7.5 cm width (larger than a deck of cards), black in color, bleeding and red, it had an odor. It had an unlabeled gauze just below brief. There was a lot of eschar around this wound. LPN #1 said the nurses change the sacral dressing as needed, approximately once per day. LPN #1 said the treatment was to clean it and apply gauze. She took off gloves to get tape out and wrote date and time and initials on the tape. LPN #1 assisted Resident #50 to roll to the right side. LPN #1 looked at the left hip/buttocks and said it looked like there was a soiled dressing left inside the wound bed of the left buttocks area with gauze stuck in it. LPN #1 cut a new gauze with scissors and stuffed it into the wound on the left hip/buttocks area. -LPN #1 failed to follow the wound care orders during the observed wound care as described above. LPN #1 did not follow the prescribed order for the left buttock wound, by not cleaning the wound, patting dry, inserting calcium alginate, or wrapping with conventional dry dressing. -The lack of nursing hand hygiene and sanitary practices with wound care treatment potentially contributed to the sacral wound infection (see wound doctor interview) and put the right heel wound at risk for infection. Cross-reference F880 failed to provide wound care in a manner to prevent potential cross contamination of infectious matter. -Resident #50 was cooperative throughout wound care treatment with no refusals of care or positioning. C. Record review The initial admission nursing assessment dated [DATE] revealed the Resident #50 had no skin issue on the right heel or the sacral area. The only skin issues present on admission: top left foot injury from fall at home during a transfer; right inner ankle dry skin; left inner ankle dry skin. The 11/5//21 Braden scale for predicting pressure sore risk revealed the resident was at moderate risk of developing a pressure sore. Risk factors included the following impairments: The resident was very limited in ability to respond meaningfully to pressure-related discomfort. The resident was only able to respond to painful stimuli and/or could not communicate discomfort except by moaning or restlessness or had a sensory impairment which limits the ability to feel pain or discomfort over half of her body. The resident's skin was occasionally moist, requiring an extra linen change approximately once a day. Ability to respond meaningfully to pressure-related discomfort was very limited. The resident's ability to walk was non-existent, she could not stand on her own weight and/or must be assisted into a chair or wheelchair. Mobility was very limited and the resident was not able to make slight changes in body positioning independently. The resident's usual food intake pattern was inadequate and she rarely ate a complete meal. The resident's exposure to friction and shear was a potential problem because movement can cause friction against the skin causing impaired skin integrity. Resident #50 admitted to hospice care 10/22/21 due to sepsis related to urinary tract infection. On 11/18/21 at 8:55 a.m, during the wound care doctors rounds, the DON said hospice agreed to allow wound care oversight by the weekly physician wound care rounds. The 11/11/21 wound care note revealed the following. -Right heel, diagnosed 9/9/2020, stage III pressure injury/ulcer, not healed. -Left buttocks, diagnosed 9/21/21, status post surgical, not healed. -Sacrum, diagnosed 11/10/21, unstageable pressure injury/ulcer, not healed. Resident #50 was seen at the hospital 11/15/21 due to altered mental status, sepsis related to urinary tract infection. The 11/15/21 after hospital visit summary report revealed the resident was admitted with the following wounds: -Pressure injury of skin, unspecified injury state, unspecified location. -Stage 3 pressure ulcer of buttock. -Skin ulcer of sacrum, unspecified ulcer stage. -Skin ulcer of heel with fat layer exposed, unspecified laterality. The resident returned from the hospital on [DATE]. The comprehensive care plan for skin integrity initiated 3/6/16 and last revised 11/14/21, revealed the resident had potential impairment to skin integrity. Interventions included avoidance of scratching, keep hands and body parts from excessive moisture, and keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage resident to change positions/turn and reposition frequently to offload pressure risk areas. She was on a repositioning program, revision 10/1/21. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Low air loss (LAL) mattress on bed and cushion in wheelchair. Resident educated on the risks of not repositioning and maintaining her weight, revision 10/1/21. Skin prevention treatments per order. Treatment to the right heel per physician orders. Wound nurse to evaluate weekly. Wound doctor to see resident weekly. Weekly skin checks by nurse, document findings. The computerized physician orders (CPO), medication administration record (MAR), and treatment administration record (TAR) wound care orders revealed the following: -Wound care, per wound doctor (WD), to the right lateral foot, apply sure prep, one time per day, every other day. Start date 11/6/21. -Wound care, right heel, cleanse with wound cleaner, pat dry, apply medi honey to wound bed on ankle and heel, cover with army battle dressing (ABD), wrap with kerlix one time per day, every other day. Start date 8/9/21. -Cleanse surgical pocket to left buttock with normal saline (NS) pat dry. Insert calcium alginate gently, pack the pocket and cover with conventional dry dressing (CDD) one time per day. Start date 11/5/21. -Cleanse area to the left and right ischium, pat dry and apply sure prep one time a day for skin integrity. Start date 10/7/21. -Apply sure prep to sacral area for skin integrity two times a day for skin integrity. Start date 6/4/2020. -Cleanse area to sacrum, pat dry. Apply betadine (may substitute Dakins until betadine arrives) to the sacral area, then cover with ABD one time per day. Start date 11/20/21. On 11/17/21 at 10:11 a.m LPN #1 failed to follow the wound care orders during the observed wound care as described above. LPN #1 did not follow the prescribed order for the left buttocks wound, by not cleaning the wound, patting dry, inserting calcium alginate, or wrapping with conventional dry dressing. Cross reference to F880 for lack of infection control measures. The 11/9/21 nurse note documented: It was reported to this nurse that the resident has a new open area to her coccyx, the site was semi-dry around the edges and slightly dry to the center did have some very minimal moisture to the site. The edges of the site have some rolling and are dry. The site measures (6.3 x 3.0 centimeter (cm)) this nurse did note red erythema around the site with purplish/reddish coloring to the center of the site. The resident denied any associated pain or discomfort to the site, she was unaware she even had the site to the back. Resident voiced she did not feel that. This nurse will update the residents power of attorney (POA) who was also her daughter, the attending nurse practitioner has also been updated. The site has been cleaned and dressed, a treatment order to be completed. The wound doctor (WD) will follow up and assess the site in rounds. The 11/11/21 registered nurse (RN) skin/wound note documented: Resident was seen today at the bedside for wound rounds with the WD. The area to her right dorsal foot has decreased in size and improved quality. A small area of fibrous tissue noted no drainage or odors noted no signs/symptoms of infection. Peri wound was healthy. Pressure to the right heel was decreased in size with healthy tissue to the wound bed. Minimal amount of drainage with a callous noted to the peri wound. The surgical wound to her left buttock was decreased in size and depth, moderate serous drainage noted periwound was healthy, no maceration or denuded areas noted. A new area of pressure was noted to resident's sacrum, 50 percent eschar noted to wound bed and a reddened periwound scant drainage noted. Treatments are in place resident continues with the use of a LAL mattress and was offered to turn frequently which she will agree to but then will remove any propping pillows and roll onto her back shortly after being repositioned. WD did note that skin failure was unavoidable at this time related to immobility, incontinence, uncooperative with movement and malnourishment despite staff efforts. Dietary will be consulted for further recommendation, resident does have a history with self sabotaging the progress of her wounds and her own personal health. The resident will continue on wound rounds at this time. -Review of the resident medical record and progress notes between 9/1/21 and 11/17/21, failed to reveal documentation of the resident refusing repositioning. The MDS documented that Resident #50 had no behaviors or rejection of care and required extensive assistance from two staff persons for bed mobility, and transfers. Physician wound care notes service date 11/18/21 read in part: Patient assessment and chronicle contributing conditions. Assessment: Healing is expected to delayed (sic) due to the identified factors and inevitable effects of aging. Physician wound care notes service date 11/18/21 read in part: Wound assessment: -Right dorsal foot, diagnosed 8/6/2020: Etiology: trauma. Measurement:1.2 centimeters (cm) x 0.6 cm x UTD (unable to determine depth). Prior dimension 0.7 (cm) x 0.5 cm x 0 cm. Scab 100%. No drainage. Progress: Stable. Treatment: sure prep, and cover with absorbent sterile gauze. -Right heel, diagnosed 9/9/2020: Etiology: pressure stage 3. Measurement: 2.3 cm x 3.2 cm x UTD. Prior dimensions: 3.3 cm x3.3 cm x UTD with 30% granulation (important component in the wound healing process) , 70% eschar (a dry, dark scab of dead skin), Drainage: scant. Periwound: callous. Progress: better. Treatment: medihoney, and cover with absorbent sterile gauze. -Left buttock, diagnosed 9/21/21: Etiology: surgical. Measurement: 0.5 cm x 5.3 cm x 1.0 cm. Prior dimensions: 1.0 cm x 3.5 cm x 1.0 cm. 100% granulation, Drainage: moderate (serum) Periwound. Progress: stable. Treatment: calcium alginate dressing. -Sacrum (lower spine) unstageable pressure wound, diagnosed 11/10/21: Etiology-pressure. Measurement: 9.5 cm x 1.0 cm x UTD. Prior dimensions: 4.0 cm x 7.5 cm x UTD. 90% eschar, 10 % epithelial (thin tissue that lines the outer surface) with tunneling. Drainage: seropurulent Periwound:. Progress: worse. Treatment sure prep and cover with absorbent sterile gauze. -Mid back, diagnosed 11/18/21: Etiology deep tissue wound. Measurement: 4.0 cm x 13 cm x 0 cm. 100% epithelialization (the rebuilding of skin cells. Periwound No drainage. Treatment: SP QD. D. Staff interviews The wound doctor (WD) was interviewed on 11/18/21 at 8:49 a.m. with the DON present. The WD said he observed the resident's wounds this morning and had treated Resident #50 one time per week for over one year. He said he made recommendations and changes for the resident's wound care throughout that time and expected the nurses to perform the daily wound care per his orders. He said he relied on the nurses to alert him of any new problems. He said the sacral wound had gotten worse when he saw it 11/18/21. The WD said he would consider the sacral wound infected based on the drainage. The WD said he considered the sacral wound to be a pressure ulcer and not a Kennedy ulcer as the DON put forward during wound rounds with the WD. The WD said the marks on the resident's back were new and that she would benefit from a different mattress. The DON said the resident was provided an air mattress by the hospice provider but that they could change it to an alternating air mattress. The DON said she instructed the CNAs on incontinence care and expected the CNA to change the resident as often as she tolerates. The WD said the wound care treatment order for the wound on the resident's left buttocks was to apply calcium alginate to the wound. The DON and the WD were informed that during the wound care observation on 11/17/21 the physician's orders were not followed by LPN #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that a resident received timely assessment and treatment for severe pain starting after a fall where major injuries resulted for one (#109) of four residents reviewed for falls out of 32 sample residents. Record review and interviews revealed the facility failed to recognize and effectively assess the resident's continued expression of uncontrolled pain as symptoms of major injuries sustained following a fall in the facility. This failure led to the resident experiencing severe pain for 48-hour delay in treatment for injuries. Resident #109 was admitted to the facility after experiencing a decline in ability and weakness in motor skills and functional ability. The resident obtained a urinary tract infection, which contributed to health declines and ended up requiring emergency room treatment, hospitalization and inpatient rehabilitative therapy on two occasions prior to the resident being admitted to the facility for care. The resident was admitted to the facility on [DATE] due to functional decline and was assessed to need extensive assistance with all activities of daily living (ADL). The resident had a history of prior fall and had chronic pain related to a diagnosis of polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) which per physician assessment was being managed with routine and as needed pain medications. The physician did increase the resident dose of Baclofen medication to address the resident's muscle spasms and associated muscle pain. The resident's records documented that the resident had an unwitnessed fall on 11/11/21 at approximately 5:30 a.m. When assessed, the resident reported thinking it was time for work and then tried to get out of bed. The resident was found on the floor on hands and knees. The registered nurse assessment of the resident reviewed no visual signs of bodily deformity or other injury. The resident immediately complained of hip pain. An on-call nurse practitioner from the resident physician's office order an immediate single view x-ray of the resident's chest, hips, and pelvic area. Later that same day the resident physician completed a new patient history and physical examination. The physician ordered an additional x-ray due to the resident's complaints of right arm pain. The diagnostic results of the x-ray taken 11/11/21, at the facility after the resident's call revealed no significant findings of cause of resident uncontrolled pain. Over the 48 hours following the resident's fall, the resident continued to complain of severe and uncontrolled pain throughout her body and was frequently unable to describe or pinpoint the exact location of the pain. In addition to routine pain medications (gabapentin) and muscle relaxant medication (baclofen), the resident was given as needed narcotic pain medication (hydrocodone-acetaminophen) and as needed muscle relaxant medication (clonazepam). Despite prescribed medication, the resident continued to experience severe uncontrolled pain. The medical record revealed the resident would sleep following the administration of narcotic medications and resume yelling out and complaining of pain when the medication started to wear off and in the time frame between the resident being able to receive another dose of medication. None of the treating nurses alerted the resident's physician that the resident pain persisted or that pain mediation was ineffective to manage the resident pain. Failure to alert the resident physician or seek additional treatment measures delayed proper diagnosis and treatment of the resident's injuries. On 11/13/21 at 5:34 a.m., 48 hours after the resident fell, the facility made a determination to send the resident to the emergency room for further assessment of injuries. The resident was assessed and required impatient treatment for fall related injuries over five days from 11/13/21 to 11/18/21. Fall-related injuries included a fractured right elbow, two fractured ribs and a pleural effusion (see hospital findings documented below). Findings include: I. Facility policies and procedures The Fall Prevention Program policy, dated 2021, by the nursing home administrator (NHA) on 11/17/21 at 2:30 p.m. The policy read in pertinent part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. When any resident experiences a fall, the facility will: -Assess the resident. -Complete a post-fall assessment. -Complete an incident report. -Notify physician and family. -Review the resident's care plan and update as indicated. -Document all assessments and actions. -Obtain witness statements in the case of injury. II. Resident #109 A. Resident status Resident #109, under the age of 65, was admitted on [DATE] and was admitted to hospital 11/13/21 According to the November 2021 computerized physicians orders (CPO) diagnosis included urinary tract infection, reduced mobility and polyneuropathy. The 11/3/21 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive assistance with a two plus physical assist with bed mobility, transfers and was total dependent on staff to use the toilet. The resident was not steady, and was only able to stabilize with staff assistance; the resident did not walk and used a wheelchair with staff assistance to navigate the environment. Direct care staff did not believe the resident was capable of increased independence. The resident was frequently incontinent of bowel and bladder and was not on a toileting program. The resident was on scheduled and as needed pain medications to treat constant pain the resident described as limiting her daily activities and assessed to be at a level of seven out of 10 (on a scale from zero to 10, with 10 being the severe pain). The resident had experienced falls in the last month and in the past two to six months, the assessor was unable to determine if the resident had any fall-related fractures in the past six months. B. Resident interview Resident #109 was not available for interview and observation, during the investigation, due to being in the hospital and being treated for fall-related injuries. Resident #109's representative was interviewed on 11/19/21 at 12:46 p.m. The resident's representative said Resident #109 had been in and out of the hospital twice prior to being admitted to the facility. The representative said the resident had a severe urinary tract infection. She was treated in the hospital and went home, but the resident's condition soon worsened and the resident was unable to stand, walk or transfer herself. Because the cause of the resident's decline was unknown and there was no caregiver in the home, Resident #109 was taken back to the hospital. Diagnostic test revealed the resident still had a UTI. Resident #109 was sent to the facility for rehabilitation and strengthening with the goal to eventually discharge to an assisted living facility. The representative said the resident was admitted to the isolation unit because she was only partially vaccinated against COVID-19 and needed to be quarantined for 14 days before moving to a room on one of the main units. The resident was very isolated on the unit, reporting that she barely saw the staff and had a hard time getting them to respond to requests for pain relief. The representative said the resident has chronic pain and had difficulty managing the pain at home and when Resident #109 stated to call the representative and complain of unrelieved pain the representative initially thought the resident was waiting until the last minute to request prescribed as needed pain medication and advised the resident to let the nurse know the minute she was feeling pain so that her pain could be better managed. The representative said she received a call on 11/11/21 from the facility nurse explaining that Resident #109 had a fall and the x-rays were negative for fractures. Later that evening (at 7:35 p.m.) the representative received a call from Resident #109 who was screaming in pain and asking for 911 to be called because the staff were not responding for pain relief. The representative said she tried to calm Resident #109 and requested she work with staff for pain management since earlier x-rays were negative for fractures. The next day the representative learned Resident #109 called 911 herself after talking with the representative on 11/11/21, because she felt her pain was not normal. The paramedics arrived but after consultation with the facility staff and the resident's physician, it was deemed unnecessary for Resident #109 to be taken to the hospital. The representative was concerned that the resident had gone days before being treated for injuries from a fall causing severe pain. C. Record review 1. Pre admission paperwork Pre admission paperwork from the hospital, dated 10/21/21, documented Final diagnoses: .urinary tract infection without hematuria, site unspecified generalized weakness.Will likely need placement in a skilled nursing facility; physical therapy and occupational therapy. History: Patient was admitted about a month ago with neuropathy syndrome as well as generalized weakness . She normally lives alone and has been having a friend help her . She returned to the emergency department today due to the impaired mobility and her friend has been working on trying to get her into a skilled nursing facility, which the patient will require at this time as she failed outpatient management. 2. Baseline care plan The baseline care plan, dated 10/30/21, revealed the resident was a fall risk and had no reported pain. -The baseline care plan identified the resident care needs but failed to identify services and treatments to be administered by the facility and personnel acting on behalf of the facility. 3. Fall assessment The resident was initially assessed to be at moderate risk for falls on the admission fall assessment scale, dated 11/11/21 at 5:55 a.m., but later in the day (11/11/21 at 7:31 p.m.) after a fall that resulted in uncontrolled pain the resident was reassessed on the same fall assessment scale and was found to be at high risk for falls. Predisposing factors included impaired gait: difficulty rising from chair, uses chair arms to get up, bounces to rise; keeps head down when walking, watches the ground; grasps furniture, person or aid when ambulating; and inability to walk unassisted. The resident was overestimating and or forgetting limits. 4. Comprehensive care plan The comprehensive care plan, dated 10/29/21, revised 11/11/21 in pertinent part, the plan documented the following resident care focus needs: Need for care assistance: The resident had an activities of daily living (ADL) self-care performance deficit related to requiring extensive dependent assistance with all ADL's, toileting and bathing. The care plan failed to detail care interventions for each ADL care task (bathing, bed mobility, dressing, eating, oral care, personal hygiene, toilet use, and transfers). Fall risk: Resident had an actual fall 11/11/21, no injuries at this time. Interventions included: -All staff to ensure frequently used items on her bedside stand close to her bed, -Call bell should always be within reach. -Nursing staff will ensure that the bed is lowered to the floor. -Nursing staff will monitor neuro-checks once a shift is ordered. -The care plan failed to document the resident history of falls prior to admission. Pain management: Resident had chronic pain with the goal that pain will be managed to the greatest extent possible so that it did prevent day-to-day activities -The care plan failed to include any intervention for pain management to control a diagnosis of polyneuropathy or other pain, or the resident's increased complaints of uncontrolled pain following an unwitnessed fall on 11/11/21. 5. Medication orders -Baclofen tablet 20 milligram (mg), give 20 mg by mouth three times a day for muscle spasms, start date 11/9/21. Scheduled to be administered at 8:00 a.m., 1:00 p.m. and 8:00 p.m. -Gabapentin tablet 600 MG, give 600 mg by mouth three times a day for neuropathy, start date 10/30/21. Scheduled to be administered at 8:00 a.m., 1:00 p.m. and 8:00 p.m. -Clonazepam tablet 0.5 mg, give 0.5 tablet every 8 hours as needed for muscle spasms, start date 11/9/21. -Hydrocodone-acetaminophen tablet 5-325 mg, give one tablet every 6 hours as needed for moderate pain #3-5 out of 10, start date 10/29/21. -Hydrocodone-acetaminophen tablet 5-325 mg, give two tablets every 6 hours as needed for moderate pain #6-10 out of 10, start date 10/29/21. -Ibuprofen Tablet 600 mg, give 600 mg by mouth every 6 hours as needed for mild pain or fever, start date 10/29/21. 6. Progress notes and assessment Administration orders dated 11/11/21 at 5:05 a.m., read in part: Hydrocodone acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .as needed administration for complaints of pain in lower extremities pain rated 8/10. The medication was: Ineffective. Nurse assessment post fall review dated 11/11/21 at 5:50 p.m. documented Resident #109 had an unwitnessed fall in the resident's room. Per the assessment, the resident was engaging in an unassisted transfer from bed and fell forward on her hand and knees. The resident was wearing regular socks. When asked what happened the resident stated she was getting up because she thought she had to go to work. The nurse indicated the resident had recent medication adjustments but was not taking any medication prior to the fall that may have attributed to the resident falling and was not showing signs of mental status change. Upon physical assessment for injuries the resident complained of severe hip pain and was unable to bear weight. -The accuracy of the post fall report was uncertain because the medication administration record and progress notes revealed the resident was given two 5-325 mg hydrocodone acetaminophen tablets at 5:05 a.m., 25 minutes before the discovery of the resident's fall. Which could have accounted for a mental status change and the resident's diminished ability to identify more areas of pain/injury may have warranted further assessment. Nursing note dated 11/11/21 at 5:56 a.m., read in part: Situation - change of condition . evaluation: fall, pain - uncontrolled) . Neurological status: Nursing observations, evaluation, and recommendations are: Resident found with both knees and both hands on the floor her buttocks in air in her room next to her bed. Resident stated she thought she had to go to work. Resident denies hitting her head; however, resident complained of pain to right and left hip upon palpation noted. No noted bruising, contusions, or deformities to extremities. Neurological within normal limits (WNL). Range of motion (ROM) WNL for the resident. Max assistance from staff to get residents into bed. Head non-tender to touch with no noted bruising or contusions. Primary care provider responded with the following feedback: Recommendations: New order received for immediate x-ray to right, left hip and pelvis. Administration orders dated 11/11/21 at 9:39 a.m., read in part: Hydrocodone acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .as needed administration was: Ineffective - resident continues to yell out and states she hurts, x-rays have been completed, awaiting results. Follow-up pain scale was: 7. Administration orders dated 11/11/21 at 12:47 p.m., read in part: Clonazepam 0.5 mg tablet . every eight hours as needed for muscle spasms take 0.25 mg - resident having increased muscle spasms causing increased pain as well. Administration orders dated 11/11/21 at 12:47 p.m., read in part: Hydrocodone acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six as needed administration for resident having increased pain all over, declines any other interventions offered. Nursing note dated 11/11/21 at 1:51 p.m., read: Resident's physician was in facility today and saw resident, resident told the physician that her hips don't hurt and she does not recall her fall in the early morning today, x-ray results of her hips and pelvis were obtained and reported to physician, chest x-ray faxed to physician's office. Resident told the physician that her right arm hurt. The physician gave a verbal order for a two view x-ray of the resident's right humerus and right forearm due to increased pain. Physician's note dated 11/11/21, read in pertinent part: Date of Encounter: 11/11/2021 Medical Necessity of Visit: New patient visit to establish care. Chief Complaint: This is an admission health and physical on Resident #109. The Patient . presented to the emergency room with an inability to ambulate and two recent falls secondary to neuropathy and was unable to maintain her ADLs. She was treated for UTI during hospitalization before being discharged to long-term care. Hospital records show that she was admitted on e month prior with neuropathy syndrome as well as generalized weakness and underwent extensive workup that did not demonstrate any repairable pathology. At that time, she was discharged to a rehabilitation facility where she was ultimately discharged back to her apartment only days prior to readmission to hospital as described above. -History of Present Illness: The patient was seen for repeated falls. Patient states she had two recent falls due to weakness prior to her last hospitalization. Nurse informed me that she had another fall this morning where it appeared that she rolled out of bed, which is at a low height. She was found on all fours on the floor. Patient at that time apparently was complaining of severe pelvic pain. X-ray of the pelvis was ordered which showed no acute osseous abnormalities. During the exam today, the patient stated no pelvis pain but was complaining of severe right arm pain. She was unable to locate the pain and stated her whole arm hurt. -Resident #109 is reportedly stable with respect to chronic pain syndrome. Possible alcohol polyneuropathy. Patient was admitted on Norco 5/325 one to two tablets every six hours PRN, ibuprofen 600 mg q six hours as needed, baclofen, and gabapentin 600 mg. - Musculoskeletal: Decreased strength of upper/ lower extremities. No gross anatomical abnormalities are noted in the right upper extremity but the patient does not allow examination due to complaints of pain. - Assessment and Plan: Repeated falls: With respect to patient's repeated falls - discussed fall prevention with patient. Ordered two view x-rays of right humerus and right forearm. Continue to monitor. Behavior note dated 11/11/21 at 1:54 p.m., read: Resident continued to call out all morning in pain, at lunch time resident told the certified nurse aide (CNA) she was too cold to feed herself and asked for CNA to feed her . continued to yell out in pain, resident stated she was having bad muscle spasms as well, also stated her hips hurt, pain medication and muscle spasm medication given to resident, resident at this time is resting. Administration orders dated 11/11/21 at 7:39 p.m., read in part: Hydrocodone acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six hours as needed administration resident requested pain medication for complaints of pain to the right and left hip. Pain related 7/10. Nursing note dated 11/11/21 at 9:17 p.m., read in part: Note Text: At approximately 7:20 p.m., this nurse heard the resident's call light and responded. Resident stated that she was in severe pain to right hip as well as left hip and this nurse administered pain meds Norco 5/325 mg at approximately 7:35 p.m. At approximately 8:00 p.m., the ambulance arrived at the facility and told this nurse that the resident had called 911. This nurse briefly explained to the paramedics the resident's medical condition, and that the resident's physician had assessed the resident's situation this morning due to the history of a fall this morning . All x-ray to bilateral hips, pelvis and humerus were performed this morning. All x-ray tests on resident, so far have all come back negative results. The resident decided she should not go to the hospital with paramedics, and is now resting in bed with the pain medication taking effect. Administration orders dated 11/12/21 at 6:00 a.m., read in part: Clonazepam 0.5 mg tablet . every eight hours as needed for muscle spasms take 0.25 mg - resident having increased muscle spasms causing increased pain. Administration orders dated 11/12/21 at 6:09 a.m., read in part: Hydrocodone acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six hours as needed administration resident requested pain medication for complaints of pain having all over her body. Pain related 8/10. Nursing note dated 11/12/21 at 6:13 a.m., read in part: Resident slept in bed with eyes closed comfortably since yesterday at 8:30 p.m. until 5:50 p.m. this morning. The CNA's entered the resident's room to provide care for the resident. Resident started yelling and hollering aloud. This nurse went into the resident's room asking the resident what was going on. Resident replied in pain. Administered Norco 5/325 mg, two 2 tablets at 6:10 a.m. as well as clonazepam 0.5 mg at 6:10 a.m. related to resident having increased muscle spasms causing increased pain noted. Will report to oncoming nurse. Nursing note dated 11/12/21 at 2:58 p.m., read: Resident continues on neurological checks which are at baseline and no increased screaming or yelling this shift and no calls to outside emergency medical assistance. Resident was asleep most of the shift and remains at baseline on her neurological checks related to fall yesterday. Administration orders dated 11/12/21 at 5:46 p.m., read: Clonazepam tablet 0.5 mg, give 0.5 mg tablet by mouth every 8 hours as needed for muscle spasms take 0.25 mg. Administration orders dated 11/12/21 at 5:46 p.m., read: Hydrocodone acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six hours as needed. Administration orders dated 11/13/21 at 4:32a.m., read: Hydrocodone acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six hours as needed administration resident unable to express where pain is, continued yelling out. Nurse note dated 11/13/21 at 5:34 a.m., read in pertinent part: Situation: Change in condition: Resident had altered mental status and pain (uncontrolled). Seems different than usual. Pulse 110 beats per minute . - Neurological status evaluation: Nursing observations, evaluation, the resident was yelling out in pain and was inconsolable, pain medication not effective. Primary care provider notified that the resident was sent to the emergency room for evaluation. Nurse note dated 11/13/21 at 6:00 a.m., read in part: Late Entry: This writer was alerted that Resident #109 woke around 4:00 a.m., yelling out and saying ow, ow, ow but unable to communicate where her pain was. This writer entered the room and the resident continued to yell out and would not respond to questions. She was unable to say where she had pain and when asked to just say yes or no responded to all touch with a grimace. It was noted that she was sweating and was pale in color. She did shake her head yes when asked if she wanted as needed pain medication. Pain medication was administered. A second registered nurse (RN) was asked to assist in the assessment. While trying to identify any areas of concern. The resident repeatedly grabbed her left hip yelling no, staff did attempt an assessment of left lower extremity and to also complete incontinence care but this caused a lot of discomfort and assessment was unable to be fully completed. No bruising or discoloration noted to hip, leg, pelvis or back area. X-rays had been completed of bilateral hips and pelvis, and her shoulder the day before with no findings. This writer and second RN did attempt to calm the resident with low gentle speaking and hand holding for support as well as a cool cloth to wipe her face and neck. This did seem to be effective and the resident was able to settle for a few minutes and drink some water but then continued to yell out. At this time it was determined that the best action was to send the resident out for evaluation. 911 was called and also unable to complete an assessment or vital signs due to the resident's discomfort. Review of the resident's MAR from 10/29/21-11/13/21 revealed the Ibuprofen order as needed every 6 hours was not administered. D. Post fall hospital report Hospital discharge placement notes emergency department admission to the hospital, admission dated 11/17/21 was reviewed. The report documented: Resident #109 presented to the emergency room on [DATE] in acute distress. She was disoriented and confused and unable to answer questions. The resident had no obvious signs of injury but appeared to be tender all over. The resident responds to her name but grimaces, moans and calls out ouch through the exam. Initial assessment documented the resident had a liver laceration unrelated to trauma; right elbow injury; and altered mental status. Diagnostic and radiologic results Chest/abdominal/pelvic CAT scan: impression: -Right lung pleural effusions (buildup of fluid), which are partially blocking air flow. No secondary signs of pulmonary hypertension or right heart strain. -Very mild heterogeneity (differences) along the parenchyma (liver tissue) which is nonspecific but could represent grade a mild injury depending on mechanism of the fall. -Subacute (non-displaced crack in the rib) to chronic (untreated, rib fractures will lead to serious short-term consequences such as severe pain when breathing, pneumonia and, rarely, death) left anterior (where the rib attaches to the breastbone) 4th and 5th rib fractures. This patient is being admitted to inpatient status for the diagnosis of altered mental status. It is expected that the patient will remain in the hospital for at least two midnights. This patient cannot be safely treated as an outpatient due to need for urgent consultation. Risks from this illness include respiratory failure. Other injury: Occult (a fracture that is not readily visible, present diagnostic challenges) closed fracture of right elbow, soft cast in place - seen by surgery no surgical intervention needed but will need pain control. Discharge was recommended return to prior facility with skilled level of care. E. Staff interviews The director of nursing (DON) was interviewed on 11/18/21 at 12:30 p.m. The DON said Resident #109 was admitted with a need for skilled nursing services to build strength in her muscles and improve ability to perform ADLs. The resident had several falls while at home. Because the resident was not fully vaccinated, she was quarantined for the first 14 days of admission, but had started rehabilitative therapy in her room. The resident had expressed some loneliness because she was unable to come out of her room and join others in activities and for dining. The DON said on 11/11/21 during 5:00 a.m. rounds, the resident was found on her hand and knees. When asked what happened, the resident said she tried to get up because she thought it was time to go to work. The nurse on duty assessed the resident for injuries, as the staff started to get the resident up off the floor the resident was yelling in pain and grabbing at her hips. The nurse consulted with the physician on call services and x-ray of the resident hips and pelvis were ordered and all came back negative for fractures. The resident's physician was in the facility to assess the resident and thought the resident complaints of pain were related to behavioral factors impacted by being in isolation and if she were moved to a regular resident unit where she could participate in offered activities she would feel better. The resident was moved out of isolation and to a unit where other residents resided. The resident was provided as needed narcotic pain medication and would sleep after administration of the medication but would wake up screaming in pain and was inconsolable; the prescribed pain medication was ineffective. Two midnights later the resident was sent to the hospital for further assessment because she could not stop screaming out in pain and could not be consoled. The physician was notified of that decision. The DON said the RN was expected to conduct a head-to toe assessment after a fall. If there were no malformation of the resident bone structure and there were no concerns with the resident's ability for range of motion, the nursing staff would notify the physician of the findings and continue to monitor the resident for possible changes in condition. The nurse was expected to notify the physician of new and developing changes in condition including signs of shock; internal bleeding; new and developing pain: and signs of pain upon palpation or body area. CNA #8 was interviewed on 11/18/21 at 1:02 p.m. CNA #8 said she worked the overnight shift on 11/12/21. Resident #109 was agitated all night and was yelling out at the beginning of the shift and the nurse got her settled with pain medication then she slept. On the last rounds at approximately 4:00 a.m. Resident #109 started to holler out in pain. Resident #109 was having more pain when she admitted her demeanor had changed because of the pain. RN #1 was interviewed on 11/18/21 at 1:49 p.m. RN #1 said she assessed the resident after her fall on 11/11/21. At approximately 5:30 a.m., the resident was found on the floor on her hands and knees. The resident kept screaming I fell, I need help! A pillow was placed under the resident's abdomen to make her comfortable while being assessed, the resident was on the floor for 30 minutes before being assessed before moving her off the floor. The resident was having a hard time explaining what happened and answering questions about her pain. The resident had no abdominal pain but kept grabbing at both hips and kept screaming of pain and pleading for staff to not leave her alone. After conducting a head to toe assessment, the CNA assisted to get the resident back into bed; the resident was not able to bear weight. RN #1 said she conducted an additional assessment with the resident in bed and the resident was at baseline with range of motion ability, but in a lot of pain. The RN notified the resident's physician on call services and a series of x-rays were ordered. The resident did calm initially after the administration of narcotic pain medication, but continued to experience pain throughout the day. RN #1 said later that evening around 7:30 p.m., the resident called 911 reporting severe pain. The paramedics arrived, and RN #1 explained the resident had x-rays of both hips, her chest, and arm earlier in the day and the physician had also assessed the resident that afternoon after the fall. The paramedics did not take the resident to the hospital after seeing the results of the x-rays. The RN said she thought the resident should have gone to the emergency room because of her pain and was not sure why the resident changed her mind about wanting to go to the emergency room. The RN [TRUNCATED]