**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure three (#3, #8 and #11) of six residents reviewed for accidents out of 21 sample residents received adequate supervision to prevent accidents. Resident #3 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric (upper thigh bone - hip fracture) fracture, acute pain due to trauma and orthostatic hypotension. The resident was known to be a fall risk upon admission due to her fall at home which resulted in the resident's left hip fracture. However, the fall assessment completed on 3/12/25 documented the resident had not fallen and was a low risk for falls. The facility implemented a fall care plan upon admission which included ensuring items were within the resident's reach.On 4/18/25 Resident #3 turned her call light on after using the bedside commode in her room. When staff had not responded to the call light after 15 minutes, the resident stood up from the commode and attempted to reach the toilet wipes, which were not within easy reach. The resident sustained a fall which resulted in her transfer to the hospital where she was discovered to have a right wrist fracture and right hip fracture which required surgical repair. Specifically, the facility failed to:-Implement effective fall interventions in order to prevent a fall with major injury to Resident #3;-Ensure fall interventions were consistently implemented for Resident #8; and,-Ensure Resident #11's foot pedals were in place on her wheelchair when staff were transporting the resident.Findings include: I. Facility policy and procedure The Accidents and Supervision policy, dated 3/1/25, was provided by the nursing home administrator (NHA) on 8/7/25 at 2:41 p.m. It revealed in pertinent part, “The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. “Identification of hazards and risks: The process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. “Evaluation and Analysis: The process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Both the facility-centered and the resident-centered direct approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk and identifying or developing interventions based on the severity of the hazards and immediacy of risk. “Implementation of interventions: Using specific interventions to try to reduce a resident’s risks from hazards in the environment. The process includes communicating the interventions to all staff, providing training as needed and ensuring that the interventions are put into action. “Monitoring and modification: Monitoring is the process of evaluating the effectiveness of care plan interventions. Modifications is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. The monitoring and modification process includes ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of new interventions. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency and based on the individual resident’s assessed needs and identified hazards in the resident environment.” II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture, acute pain due to trauma and orthostatic hypotension. The 3/18/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. She required full assistance of one person for bed mobility, transfers, locomotion, dressing, and toileting. The resident was incontinent of bladder and bowel. The assessment indicated the resident had a prior fall within the last month while at home, resulting in a fracture to her left hip. B. Resident and resident representative and resident representative interview Resident #3 and her representative were interviewed together via phone on 8/11/25 at 10:19 a.m. Resident #3 said she was on the commode in her room (on 4/18/25) when she pushed her call light for assistance off the toilet. She said she waited 15 minutes for staff to come and assist her but to come and assist her but no one answered her call light. She said the toilet wipes were not within reach and so she stood up from the commode to reach back behind her for the wipes and fell to the floor. Resident #3 said she laid on the floor Resident #3 said she laid on the floor until staff arrived to answer her call light. Cross reference F565 for grievances of a group related to call lights. Resident #3’s representative said the resident sustained a right wrist fracture and a right hip fracture as a result of her fall. She said the resident did not return to the facility and was discharged to another facility after her hospital stay. C. Record review The fall care plan, initiated 3/13/25, identified that Resident #3 had a potential for fall/injury related to decreased range of motion and a fall with fracture. Interventions included keeping frequently used items within reach (initiated 3/13/25), keeping the call light within reach (initiated 3/13/25), assisting with transfers as needed (initiated 3/13/25), the resident was to be supervised during toileting activities (initiated 4/18/25) and encouraging the resident to use a reacher device (initiated 4/21/25). -However, the interventions for supervision during toileting and encouraging the resident to use a reacher device were not implemented until after the resident’s fall and transfer to the hospital on 4/18/25. -Additionally, the toilet wipes were not within easy reach of the resident, which caused her to have to stand up and reach behind her to reach them (see resident interview above). The admission fall risk assessment, dated 3/12/25, revealed Resident #3 was a low risk for falls. -The fall risk assessment documented the resident had not fallen, however, the resident was admitted with a fractured hip related to a fall at home. The 4/17/25 physician’s follow-up progress note documented Resident #3 was still non weight bearing on her leg, still needed help with transfers and remained a fall risk. The 4/18/25 nurse progress note, documented at 9:35 p.m., revealed Resident #3 was sent to the hospital for Xrays. -The progress note did not document the reason the resident was sent to the hospital for Xrays or what time she was transported from the facility. The 4/18/25 nurse progress note, documented at 5:49 a.m., revealed the nurse called the hospital and was informed that Resident #3 had been admitted to the hospital. -The progress note did not indicate the reason the resident had been admitted to the hospital. The 4/19/25 nurse progress note, documented at 7:19 a.m., was documented as a late entry progress note (for the 4/18/25 fall). The progress note documented Resident #3 was assessed by the registered nurse (RN) for immediate trauma/injury. Resident #3 reported pain at her right hip with guarding (physical response to attempt to protect an injury) while being assessed. The resident was transferred to her bed with staff assistance. Once in bed, Resident #3 complained of right wrist pain with some deformity noted at the ulnar bone (long bone of the arm, on the outside of the wrist). A small amount of blood was noted from a skin tear at the ulnar side of her wrist. The physician and the resident’s representative were notified and the physician gave orders to send the resident to the hospital for evaluation and treatment. The resident was transported to the hospital via ambulance at approximately 7:30 p.m. The 4/21/25 fall/post fall progress note documented that Resident #3 stated she was reaching for the wipes and fell to the floor, extending her right hand as she was falling. The resident had turned her call light on and then reached for the wipes. The resident overreached and fell off the bedside commode. The note documented the certified nurse aide (CNA) who placed Resident #3 on the bedside commode placed items where the resident directed them to be placed. Review of Resident #3’s call light records for 4/18/25 revealed Resident #3 pushed her call light at 6:18 p.m. The duration for the 6:18 p.m. call light was 25 minutes and 19 seconds. D. Staff interview The director of nursing (DON) was interviewed on 8/11/25 at 2:40 p.m. The DON said Resident #3 initially admitted to the facility for a left hip fracture that occurred at home. The DON said Resident #3 was very careful about using the call light and waiting for staff. She said not waiting for staff to answer her call light to assist her before reaching for the wipes (on 4/18/25) was out of character for the resident. -However, Resident #3 said she turned her call light on and waited for 15 minutes for staff to come and assist her before attempting to get the wipes herself (see resident interview above). -Additionally, per Resident #3’s 4/18/25 call light log, the resident turned her call light on at 6:18 p.m. and the call light was not answered for over 25 minutes (see record review above). The DON said the facility changed nursing shifts at 6:00 p.m. and staff performed walking rounds at that time. She said the general goal for answering call lights was six minutes. She said Resident #3’s fall occurred during shift change, which was not an excuse, but justified the long wait time for the resident’s call light. The DON said staff found Resident #3 on the floor when they went in to answer her call light. She said Resident #3 did not vocalize her need for assistance. -However, Resident #3 requested assistance from staff by pushing her call light over 25 minutes before she was found on the floor when a staff member answered her call light. The DON said Resident #3 was sent out to the emergency room after the fall and was found to have a fracture to her right wrist and right hip. She said the resident did not return to the facility. The DON said a fall assessment was completed for residents at the time of admission. She said the assessment gathered information from the family in an attempt to mitigate potential issues at the time of admission. She said Resident #3 should have been documented as a high risk for falls due to her fall history at home. The DON said the facility implemented standard fall interventions for residents at admission. She said some interventions implemented were non-skid socks, fall mats, low bed position and a “call don’t fall” sign. III. Resident #8 A. Resident status Resident #8, age greater than 65 years, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, anxiety, subsequent encounter for fracture with routine healing, abnormalities of gait and mobility, generalized muscle weakness, and a history of falls. The 8/6/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a BIMS score of four out of 15. She was dependent on staff for partial to moderate assistance with most ADLs. Resident #8 has abnormalities of gait and mobility, is unsteady on her feet, and had a history of falls. The MDS assessment indicated the resident had a history of falls. B. Observations and staff interview On 8/6/25 at 9:10 p.m., Resident #8 was in her room, lying in bed. -The resident did not have the tactile wedge pillow (triangle-shaped pillow) in use. On 8/7/25 at 4:20 p.m. Resident #8 was in her bed in her room, without a tactile pillow in place. CNA #1 confirmed the tactile pillow was not in use. She said the pillow was put next to the wall, because she liked to roll on her right side. CNA #1 said the pillow was used to keep her arm on the bed, preventing her arm from falling between the bed and the wall. C. Record review The 7/5/25 fall risk assessment documented that Resident #8 was at a high risk for falls. Resident #8’s fall care plan, initiated 10/1/24, identified that the resident was at high risk for falls. Pertinent interventions included non-skid socks, a call light within reach, the bed in the lowest position, the fall mat in front of the bed and staff were to offer assistance with ADLs before and after meals. A progress note, dated 5/27/25, documented interventions for fall included a floor mat at bedside as the resident allows/tolerates when the resident was lying in bed, non-skid footwear when not in bed, when possible, non-skid socks when not wearing footwear, when possible or as tolerated by the resident, bed in a low position when in bed, positioning wedges for tactile boundaries, an anti-rollback device on the wheelchair, and check and change before and after meals and during rounds at night. Fall incident on 7/1/25 - unwitnessed On 7/1/25, the interdisciplinary team (IDT) progress note documented that Resident #8 was found on the floor, lying in front of the bed with her head towards the foot of the bed. The resident was lying on the floor with her head on a pillow and covered with a blanket. The resident declined to wear non-skid socks. A floor mat was in front of the bed. The plan is to replace the resident’s call light with a bump call light. Fall incident on 7/5/25 - unwitnessed A post-fall note, dated 7/5/25, documented the nurse went into Resident #8’s room as the roommates' call light was on and the resident was found lying on the floor on her right side. A fall mat was in place, the bed was in lowest position and the call light was within reach. The resident was found without non-skid socks on, as the resident wore non-skid slippers during the day, but had them off as she was in bed and positioning wedges for tactile boundaries were not in place. The fall assessment was completed and the resident was scored at high risk for falls. D. Additional staff interviews Registered nurse (RN) #1 was interviewed on 8/7/25 at 4:26 p.m. RN #1 said Resident #8 had a history of falls. She said Interventions used for the resident were the floor mat at bedside and the bed in the lowest position. She said she did not know about the use of the tactile pillow as an intervention for Resident #8. RN #1 was interviewed a second time on 8/7/25 at 4:39 p.m. RN #1 said she had inquired what the tactile pillow intervention was for Resident #8, and she said it was a pillow that was put at the edge of the resident’s bed so she could feel it and know where the bed boundary was. The DON and the nurse consultant were interviewed on 8/11/25 at 2:40 p.m. The DON said the facility used a fall assessment to determine the residents’ risk for falls. The DON reviewed Resident #8’s electronic medical record (EMR) and confirmed the resident was at high risk for falls. She said the resident had experienced falls. She said current interventions were to place the resident’s bed in the lowest position and ensure the resident’s call light was within reach. The DON said the interdisciplinary team (IDT), consisted of herself, the NHA, the SSD, the AD, and the physical/occupational therapist and the IDT was the staff involved with reviewing the fall evaluation post-fall incident. IV. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, history of transient ischemic attack (a brief and temporary interruption of blood flow to the brain) and history of falling. The 8/2/25 nursing admission assessment revealed the resident was confused and had short-term and long-term memory problems. She required assistance from staff for most ADLs and used a wheelchair. The nursing admission assessment indicated the resident had a history of frequent falls. B. Observations On 8/6/25 at 10:58 a.m. Resident #11 was attempting to self-propel in her wheelchair through the common area. CNA #1 transported the resident to the nurses’ station in her wheelchair. There were no foot pedals attached to the resident’s wheelchair, which caused the resident to hold her legs and feet up and off of the ground. -Other staff members were in the vicinity; however, no staff members intervened to ensure Resident #11 was not transported in her wheelchair without foot pedals. On 8/6/25 at 11:06 a.m. Resident #11 was again attempting to self-propel in her wheelchair near the nurses’ station. CNA #2 assisted the resident to her room and then to the television (TV) in the common area. There were no foot pedals attached to the resident’s wheelchair, which caused the resident to hold her legs and feet up and off of the ground. -Other staff members were in the vicinity; however, no staff members intervened to ensure Resident #11 was not transported in her wheelchair without foot pedals. On 8/6/25 at 11:37 a.m. Resident #11 was transported to the bathroom from the common area in her wheelchair. CNA #2 told the resident to lift her feet up. There were no foot pedals attached to the resident’s wheelchair, which caused the resident to hold her legs and feet up and off of the ground. C. Record review The fall assessment, dated 8/1/25, revealed Resident #11 was a high fall risk. Review of Resident #11’s care plan, initiated 8/4/25, identified Resident #11 was a fall risk. Interventions included utilizing a fall mat while the resident was in bed, keeping the bed in the low position and keeping the call light and frequently used items in reach. -However, the fall care plan failed to include an intervention to ensure Resident #11’s foot pedals were in place when she was being transported in her wheelchair in order to prevent potential falls. D. Staff interviews The director of rehabilitation (DOR) was interviewed on 8/11/25 at 1:05 p.m. The DOR said that not every resident utilized wheelchair foot pedals due to the facility’s goal to increase mobility. He said the residents’ feet should not dangle from the wheelchair or drag across the floor when staff were transporting the resident in order to prevent the wheelchair from tipping over. The DOR said each resident was fit to a wheelchair for proper fit and should have foot pedals in their room. The DON and the nurse consultant were interviewed on 8/11/25 at 2:40 p.m. The DON said a majority of the residents without wheelchair foot pedals had the ability to self-propel in their wheelchairs. She said there were foot pedals available for each wheelchair. The DON and the nurse consultant were unclear as to what was best practice for utilizing foot pedals during transport. The nurse consultant said the residents might fall trying to get out of their wheelchairs if foot pedals were attached to their wheelchairs. E. Facility follow-up On 8/12/25 at 4:52 p.m. (after the survey exit) the NHA provided an update regarding Resident #11’s care plan that documented the resident self-propelled safely without pedals and using them could hinder her mobility. -However, the care plan continued to fail to include an intervention for staff to ensure Resident #11’s foot pedals were in place when she was being transported by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure three (#13, #17 and #5) of four residents reviewed for accidents out of 24 sample residents remained free from accidents. Resident #13, who was identified with osteoporosis after a pathological (fracture caused by disease processes rather than trauma) right femur fracture (thigh bone above the knee) that required hospitalization and surgery on 6/22/24, sustained a non-displaced [NAME] fracture (an ankle injury that involves a fracture of the proximal fibula) on 1/12/25. The facility failed to ensure and document a root cause analysis and implement timely person-centered interventions after Resident #13 sustained a right femur fracture on 6/22/24. Additionally, the facility failed to schedule osteoporosis screening and treatment which was recommended after the resident had surgical repair to the fractured right femur. The facility failed to ensure and document a root cause analysis and implement timely person-centered interventions after Resident #13 sustained the right fibula fracture on 1/12/25. Additionally, Resident #17 was admitted to the facility on [DATE]. Upon admission the facility implemented fall interventions as the resident was determined to be a fall high risk. On 11/17/24 Resident #17 sustained an unwitnessed fall and sustained a concussion, a contusion (bruise) to the knee, a laceration of the forehead and cervical strain related to her fall. The facility updated the resident's fall care plan on 11/22/24 to include placing a floor mat at her bedside whenever she was in bed. However, observations revealed the facility did not consistently implement the fall mat while the resident was in bed (see observations below). On 1/11/25 Resident #17 sustained another unwitnessed fall when she attempted to self-transfer from her wheelchair to her bed. The fall care plan did not document any new interventions. The facility initiated 15-minute checks overnight for the resident on 1/16/25, however the facility did not update the resident's care plan to include the 15-minute checks. On 2/3/25 Resident #17 sustained another unwitnessed fall, the cause of which was not determined. Resident #17 sustained another unwitnessed fall on 2/4/25 when she attempted to self-transfer from her wheelchair to a sofa in the main living area. Upon evaluation, it was found Resident #17 sustained sacral insufficiency fractures (stress fracture). The facility failed to implement new person-centered fall interventions to prevent future falls. Also, the facility failed to complete a thorough root cause analysis to determine how Resident #5 obtained a skin tear. Findings include: I. Facility policy and procedure The Incidents/Accidents policy and procedure, revised September 2016, was provided by the nursing home administrator (NHA) on 2/27/25 at 3:11 p.m. It read in pertinent part, All incidents/accidents are to be documented. In the progress notes document the date time and location of the incident/accident; document any assistive devices in use; vital signs should be documented; document a full description of any injuries; any resident statement of the account of the incident; document only what was observed; indicate when the physician was notified and any orders; indicate when the legal representative was notified. II. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, type 2 diabetes mellitus (DM), displaced fracture of right lower femur and non-displaced [NAME] fracture of right fibula. The 1/2/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. She was dependent on staff for toileting, personal hygiene, required substantial/maximal assistance with bed mobility, transfers and required set up assistance with eating. The assessment did not document the diagnoses of osteoporosis (disease that weakens the bones). -However, review of Resident #13's electronic medical record (EMR) revealed the resident had a diagnosis of osteoporosis. B. Observations On 2/24/25 at 1:00 p.m. Resident #13 was sitting in her room in a wheelchair with her feet down and resting on the foot rests on her wheelchair. Her right leg was in a splint. Resident #13's call light was lying on the floor next to the resident's wheelchair. A foot board (a special padded board that attaches onto the wheelchair foot rests to keep feet from sliding off) was not on Resident #13's wheelchair. On 2/24/25 at 2:00 p.m. Resident #13 was sitting in her room in a wheelchair with her feet down and resting on the foot rests on her wheelchair. Her right leg was in a splint. Resident #13's call light was lying on the floor next to the resident's wheelchair. A foot board was not on Resident #13's wheelchair. C. Resident #13's representative interview Resident #13's representative was interviewed on 2/24/25 at 2:34 p.m. Resident #13's representative said she was told by a certified nurse aide (CNA), after Resident #13 returned from the hospital on 1/12/25, that she had transferred Resident #13 by herself and pivoted Resident #13 from the wheelchair to the bed. She said she had a care conference with the facility after the 1/12/25 fracture and told the facility because of Resident #13's fractures that two people needed to transfer her at all times for safety reasons. She said the facility told her that they would be using a hoyer lift with two people at all times. D. Record review 1. Care plan The activities of daily living (ADL) care plan, initiated 4/12/23, indicated Resident #13 had impaired physical mobility due to a right lower extremity fracture. Interventions included non-weight bearing on the right lower extremity (initiated 6/30/24 and revised 1/16/25) and required two people with the use of a hoyer lift (initiated 7/16/24 and revised 1/16/25). The osteoporosis care plan, initiated 1/14/25, indicated Resident #13 had bone loss. Interventions included staff to observe for complaints of pain, completing labs per orders and reporting to the physician. The fall/injury care plan, initiated 4/6/23, indicated Resident #13 was at risk for falls and injury. Interventions included assisting with transfers/ambulation as needed (initiated 4/6/23), completing fall risk assessment upon admission and quarterly (4/6/23), instructing and reinforcing safety awareness measures (4/6/23), keeping call light in reach (4/6/23), non skid socks/footwear (initiated 6/28/24 revised 6/28/24), encouraging bed to be in low position (initiated 6/28/24) and wheelchair with foot pedals and foot board at all times (initiated 1/15/25). -However, observations revealed the resident did not have a foot board in place on her wheelchair (see observations above). -A review of the comprehensive care plan revealed the osteoporosis care plan was not initiated until 1/14/25, the wheelchair foot boards was initiated on 1/15/25 and the use of the Hoyer lift with two people was re-initiated on 1/16/25, after Resident #13 experienced a second right lower extremity fracture. 2. Incident on 6/22/24 The 6/22/24 nursing progress note, documented at 12:30 p.m., revealed Resident #13's right knee was swollen and she was unable to bend her knee. The nurse practitioner was notified. Vital signs were taken. The resident was administered Tylenol for pain in her right knee. The resident was sent out to the hospital for evaluation and treatment. The 6/22/24 physical abuse investigation documented Resident #13 complained of pain in her right knee which was revealed to be a fracture above her knee. On 6/22/24, in the morning, Resident #13 was a stand pivot transfer by a CNA and had been up to the shower, up in her wheelchair for activities and laid down after lunch. Resident #13 denied anyone hurting her and there were no behavior changes. Staff were interviewed and did not witness any event that was a causative factor. Resident #13 was admitted to the hospital and required surgery to her right lower femur (thigh bone). The surgical report revealed specialized clips were used due to her brittle bones. The report of physical abuse was unsubstantiated. -However, there was no identification of a root cause analysis being completed after the resident sustained a right lower femur fracture and there were no person-centered interventions implemented after the resident sustained the fracture. The 6/22/24 hospital progress note documented Resident #13 had a displaced fracture of the right femur and was admitted for orthopedic consult and possible surgery. The 6/24/25 hospital physical therapy (PT) note documented Resident #13 was up with two person assistance using a stand-pivot transfer on the left. Right lower extremity precautions were weight-bearing as tolerated for transfers. The 6/25/24 hospital progress note documented Resident #13 had an open reduction internal fixation (ORIF) of the right femur (a surgical procedure to realign the bone and stabilize the fracture), done on 6/23/24. It recommended an outpatient osteoporosis screening and treatment. -However, the facility failed to schedule the osteoporosis screening until March 2025, nine months after it was recommended (see facility follow up below). -A review of the EMR failed to reveal an interdisciplinary team (IDT) risk management review note of the 6/22/24 incident and root cause analysis with any interventions that needed to be implemented to prevent any further fractures. Review of the July 2024 CPO revealed the following physician's orders related to transferring the resident: -Use a Hoyer lift for transfers, ordered 7/8/24 and discontinued 7/15/24. -Weight bearing as tolerated for transfers only to the right lower extremity, ordered 7/15/24 and discontinued 7/17/24. The 8/8/24 PT discharge summary notes documented Resident #13 was substantial/maximal assistance for transfers. Review of the August 2024 CPO revealed a physician's order for the resident to be weight-bearing as tolerated, ordered on 8/16/24 and discontinued 1/12/25. 3. Incident on 1/12/25 The 1/12/25 nursing progress note documented Resident #13 was calling out in pain and had swelling and heat in her right knee and ankle. The physician was notified and an x-ray was requested of the knee and ankle. The resident was given ibuprofen for pain per physician's order. The 1/12/25 nursing progress note documented the x-ray report identified a spiral fracture to the right lower extremity. Resident #13 was sent to the hospital emergency room for evaluation and treatment. The 1/12/25 nursing progress note documented the resident returned to the facility with a cast. The 1/12/25 physical abuse investigation documented Resident #13, before she got up in the morning, complained of pain to her right leg with swelling in her right knee and ankle. The right knee and ankle were warm to the touch. The physician was notified and an x-ray was obtained. The x-ray results indicated a spiral fracture to her right lower extremity. The resident was sent to the hospital for further evaluation and treatment. The resident had no recent history of falls or trauma. The activities director (AD) reported that on 1/11/25 the resident turned herself in her wheelchair which caused the affected leg to be twisted in front and outside the front of the wheel. CNA #4 reported on 1/11/25 she changed Resident #13 before getting her up for dinner and she grimaced and complained of leg pain. She asked the nurse to assess her and the nurse gave her medication for pain. CNA #4 said she was then able to transfer Resident #13 to the wheelchair with a gait belt. The report of physical abuse was unsubstantiated. -However, there was no summary of a root cause in the physical abuse investigation or identification and implementation of interventions to prevent future fractures. Review of the January 2025 CPO revealed a physician's order to use a Hoyer lift for transfers, ordered 1/12/25. The 1/15/25 quarterly care conference documented Resident #13's transfers were to be with a Hoyer lift with two people at all times. -A comprehensive review of the resident's EMR failed to reveal an IDT risk management review note of the 1/12/25 incident and root cause analysis with interventions that needed to be implemented to help prevent any further fractures. E. Staff interviews Registered nurse (RN) #1 was interviewed on 2/26/25 at 10:00 a.m. RN #1 said Resident #13 was totally dependent on staff for transfers and required two person assist with the use of a Hoyer lift. She said prior to the most recent fracture, she was a one person extensive assistance with pivot transfers. CNA #2 was interviewed on 2/26/25 at 11:10 a.m. CNA #2 said Resident #13 was full weight-bearing before she fractured her femur bone in June 2024. She said after Resident #13 returned from the hospital in June 2024, Resident #13 required the use of a Hoyer lift until PT cleared her to be a two person transfer assist. She said Resident #13 needed a Hoyer lift after she experienced a fracture in her right leg in January 2025 for safety reasons. The director of rehabilitation (DOR) was interviewed on 2/26/25 at 11:20 a.m. The DOR said that prior to her fracture in June 2024, Resident #13 was full weight-bearing. The DOR said after Resident #13 returned from the hospital, she was maximum assistance of two people for transfers. He said an order for a Hoyer lift was in place from 7/8/24 to 7/17/24 and then she was cleared to be weight-bearing as tolerated on her right lower extremity with one to two person assistance. He said after her second fracture, she was required to be a Hoyer lift. He said he did education with nursing staff at that time on transfers, Hoyer lift use and how to manage her splint/cast. The director of nursing (DON) and the NHA were interviewed together on 2/26/25 at 11:55 a.m. The DON said prior to Resident #13's fracture in June 2024, there were no precautions in place and she was a one person pivot transfer. She said prior to the fracture in June 2024, staff were assisting Resident #13 in the morning and she was complaining of right knee swelling and pain after they put her back to bed. She said the staff noticed at that point that her right knee was swollen. She said during the investigation and staff interviews, they were unable to identify any events that happened before that may have contributed to the fracture. The DON said it was not identified until after Resident #13 had surgery in June 2024 that she had a significant osteoporosis. The DON said after Resident #13 returned from the hospital she was a two person Hoyer lift for transfers and worked with therapy to build up her strength and endurance. She said in August 2024 PT felt she could stand and pivot with her lower extremities. The DON said during the physical abuse investigation for the fracture in January 2025, staff indicated that on 1/11/25 Resident #13 was observed by staff members to be moving her wheelchair herself and had caught her right leg in front of the wheel on her wheelchair and may have twisted it. She said they reviewed camera footage and Resident #13 moved herself around in her wheelchair with poor safety awareness and would catch her leg against the door. She said Resident #13 did complain of some increased pain in the evening of 1/11/25 that was medicated with Tylenol. She said when staff tried to get Resident #13 up in the morning for breakfast Resident #13 was complaining of extreme right knee pain. The DON said staff then noticed her knee was red and swollen. She said the physician was notified and an x-ray was ordered. She said when the results of the x-ray came back positive for a fracture, Resident #13 was sent to the hospital for further evaluation and treatment. She said after she returned from the hospital, the intervention that was implemented for Resident #13 was to make her a two person Hoyer lift for safety reasons. The NHA said the facility had incident reports and physical abuse investigations which summarized their findings. She said the facility did not have a formal IDT root cause analysis which documented the findings with interventions in the resident's EMR. She said their process was informal and verbal. CNA #4 was interviewed on 2/27/25 at 1:15 p.m. CNA #4 said Resident #13 was a one pivot transfer prior to her fracture in January 2025. She said on 1/11/25 Resident #13 was up for breakfast and went to activities. She said she laid Resident #13 back down after activities. She said she tried to get Resident #13 up and she was tearful and complaining of right knee pain. She said she contacted the nurse to assess and Resident #13 was medicated with Tylenol. She said she was contacted by the facility later that Resident #13 had experienced a leg fracture. She said the facility watched the cameras for the day and they saw Resident #13 had reached down after she had twisted her leg. She said she was not aware of any other additional interventions to help prevent fractures. She said Resident #13 had foot pedals but she would take her feet off the pedals to self propel herself in the wheelchair. E. Facility follow up The facility fractures root cause analysis and timeline was provided by the NHA on 2/28/25 at 5:10 p.m. (after the survey). It documented the undated root cause of the 6/22/24 femur fracture was due to Resident #13's bone demineralization that was identified during surgery. The exact cause of the fracture was unknown. Interventions included transfers with a Hoyer lift and working with PT. On 7/15/24 she had an order by orthopedics that she could be weight-bearing as tolerated for transfers only. She was discharged from PT on 8/19/24 with a substantial maximal assistance of one person for transfers and remained wheelchair bound for mobility. The 1/12/25 fracture root cause analysis, undated, identified Resident #13's osteoporosis as a contributing factor. The resident was participating in activities and the facility suspected the resident twisted her leg when independently moving her wheelchair. Resident #13 was identified to lock her wheelchair and then tried to move forward and dragged her leg. After returning from the hospital to the facility, she was a Hoyer lift transfer, a footboard was to be in place and two people assisted for care. PT services were involved for strengthening of the upper extremity, ADLs and wheelchair positioning. The medical director letter, undated, documented a nondispaced spiral fracture of the right tibia and closed fracture of the proximal right fibula which were due to demineralization of the bone, severe peripheral vascular calcification and advancement of her comorbidities. A DEXA scan (a scan that measures bone density) was scheduled for March 2025. -However, osteoporosis screening and treatment was ordered nine months after osteoporosis was identified during an ORIF to the right femur and two months after Resident #13 sustained a second fracture to her right lower extremity. IV. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included Alzheimer's disease, dementia, cerebral vascular disease (a condition affecting blood flow to the brain), palliative care, behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 11/21/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of four out of 15. She required total assistance from staff with oral hygiene, toileting, showering, dressing and personal hygiene. B. Resident representative interview and observation The resident's first representative was interviewed on 2/25/25 at 2:52 p.m. He said Resident #5 had a skin tear on her left arm. He said the facility told him the accident happened when the staff were pushing her in the wheelchair and her arm was caught in the door latch or door frame. He said he thought it was hard to understand how that happened. He said the facility did not tell him what they were doing to prevent the skin tear from happening again. The resident's second representative was interviewed with Resident #5 present on 2/27/25 at 2:15 p.m. She said she was frustrated the resident had a skin tear on her left arm. The representative said the facility said the accident happened when she bumped a corner of a door frame. She said the cause of the skin tear was hard to understand. The representative showed Resident #5's left elbow. The left elbow had Steri-Strips (thin sticky bandages to help wounds stay closed as they heal). During the interview, the resident was scratching both of her arms. C. Observations During a continuous observation on 2/25/25, beginning at 11:25 a.m. and ending at 11:55 a.m., the following was observed: At 11:25 a.m. the resident was in her room sitting in her wheelchair next to her bed. The television was turned on. At 11:49 a.m. an unidentified CNA pushed the resident in her wheelchair out of her bedroom. Resident #5 had her left hand across her chest to her right shoulder and the right hand was resting against her right thigh on the seat of the wheelchair. -Resident #5 and her wheelchair took up approximately one-third of the door frame. D. Record review The self-care deficit care plan, revised 8/16/24, revealed the resident required assistance with dressing, grooming, bathing, personal hygiene, bed mobility and had impaired physical mobility related to weakness. Interventions included encouraging the resident to keep nails filed to prevent sharp edges (added 2/27/25, during the survey). -Review of the resident's care plan did not identify the resident was at risk for skin tears. -Review of the care plan revealed there were no new interventions implemented to prevent further skin tears for the resident until 2/27/25 (during the survey). The 2/20/25 incident report revealed the CNA reported the resident showed him her left arm. A nurse assessed the skin tear. The resident had a skin tear measuring 3 centimeters (cm) by 2.5 cm to her left forearm. The resident denied pain. The resident said I bumped it on the door. The incident report documented the wound was cleansed with wound cleaner and patted dry. The edges were approximated and three Steri-Strips were applied. There was minimal blood present so a border gauze was placed over the skin tear. The representative and physician were notified. Orders for monitoring were entered. The injury observed was a skin tear on her left antecubital (inner or front surface of the forearm). The 2/21/25 nurse progress note revealed the resident had a skin tear to her left forearm. It was cleansed with wound cleaner and patted dry. The edges were approximated and three Steri-Strips were applied. There was minimal blood present, so a border gauze was placed over the skin tear. The representative and physician were notified. Orders for monitoring were entered. The resident denied pain. -A review of the resident's EMR revealed there was no documentation by the nurse on 2/21/25 that described how the skin tear occurred. The February 2025 CPO revealed the following physician's order: Monitor skin tear to the left forearm for signs and symptoms of infection or pain every day and evening shift, discontinue when resolved, ordered 2/21/25. -A review of the resident's EMR revealed there was no documentation that revealed the IDT met to discuss the incident to identify the root cause and implement person-centered interventions to prevent further skin tears. F. Staff interviews Certified nurse aide with medication aide authority (CNA-Med) #1 was interviewed on 2/27/25 at 8:59 a.m. CNA-Med #1 said if she noticed a skin injury while administering medication, she would notify the nurse. She said skin injuries included skin tears, bruises and scratches. She said she knew what interventions were in place to prevent future injuries based on the resident's care plan. She was familiar with Resident #5. She said Resident #5 told her she bumped her arm when she sustained the skin tear. RN #1 was interviewed on 2/27/25 at 10:18 a.m. RN #1 said if she was notified of a skin injury, she would clean the skin injury site, notify the physician and the family. She said she documented what skin treatment she provided, who she notified, any new orders by the physician, a possible cause of how the resident had the skin injury and an immediate intervention to prevent the skin injury in the risk assessment section of the EMR. She said the risk assessment was not part of the resident's medical record. She was familiar with Resident #5 but did not know how she sustained the skin tear on her left forearm. The DON was interviewed on 2/27/25 at 12:20 p.m. The DON said if staff noticed a skin injury, the nurse started an incident report in risk management. The DON said the nurse was responsible for implementing an immediate intervention, completing a skin and pain assessment and obtaining orders as needed. She said the assistant director of nursing (ADON ) reviewed the incident report and modified the interventions. The DON said the IDT reviewed the incident during the next day's morning meeting and the IDT reviewed the final incident report at the end of day meeting. The DON said there was not a system set up in the resident's medical record to show all of the IDT members reviewed and signed the incident and a root cause was identified. The DON said the root cause for Resident #5's skin tear was that the resident's nails were too long and she scratched her arms due to itching. The DON said the resident had thin skin and the scratching caused the skin tear. -However, the resident reported after the incident that she bumped her arm on the door and did not scratch her arm with her finger nails (see the incident report above). F. Facility follow up The NHA provided additional documentation on 2/28/25 at 5:16 p.m. (after the survey). The documentation revealed the resident was identified to have a skin tear on her elbow on 2/20/25. The resident said she bumped it on the door. The door was examined by maintenance and there was no evidence of sharp edges. The ADON completed an investigation and did not document in the file until 2/24/25. The investigation concluded it was more likely she scratched her own arm due to itching and her nails needing a trim. There were no further incidents and her nails were trimmed. The NHA said the facility could improve its documentation and the facility would start placing an IDT note in each resident's EMR after an incident. The incident report, updated 2/24/25, revealed the resident was assessed. The resident was noted to have a skin tear to her left upper forearm. The resident started to itch her arms when asked what happened to her forearm. The resident had long nails but did not want them cut. The resident was okay with filing her nails so the edges were not sharp. -However, the facility did not provide documentation that the IDT reviewed the incident, identified the root cause and reviewed interventions to prevent future skin injuries. -Additionally, the NHA provided the incident report on 2/24/25 at 10:42 a.m. The incident report provided during the survey failed to reveal the facility determined the skin injury was not from the resident bumping her arm on a door, and did not include the facility determined the skin injury was due to itching and her nails needing a trim. III. Resident #17 A. Resident status Resident #17, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included dementia, generalized muscle weakness, osteoarthritis, osteoporosis and a history of falling. The 2/13/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS assessment score of three out of 15. The resident was dependent on staff for most ADLs. B. Resident friend and representative interviews Resident #17's friend was interviewed on 2/26/25 at 1:30 p.m. The resident's friend said she felt Resident #17 was declining and wanted to sleep all the time. The resident's friend said Resident #17 had fallen several times at the facility, during which she had fractured her tailbone and had received seven stitches in her head. The resident's friend said the falls were serious. The resident's friend said there was someone sitting with Resident #17 for ten hours per day. The resident's representative was interviewed on 2/26/25 at 1:32 p.m. The resident's representative said Resident #17 had several falls within the months prior and sustained some injuries. The resident's representative said she thought some of Resident #17's falls had been the result of her trying to get out of bed without calling for help due to her dementia. She said she had asked the facility staff how they could prevent her falls, to which the facility said they were trying to monitor Resident #17 more closely. C. Resident observations On 2/25/25 at 1:11 p.m. Resident #17 was lying in her bed. The fall mat was folded up beside the one-on-one caregiver's chair. On 2/26/25 at 9:24 a.m. Resident #17 was lying in the fetal position in her bed. The fall mat was not in place and was folded up beside the one-on-one caregiver's chair. On 2/27/25 at 1:35 p.m. Resident #17 was lying in her bed. The fall mat was folded up beside the one-on-one caregiver's chair. D. Record review The fall care plan, initiated 10/7/24, revealed Resident #17 was at an increased risk of falls and/or serious injury related to falls due to a recent fall resulting in fractured vertebrae and antidepressant medication use. Pertinent interventions, initiated on 10/7/24, included encouraging Resident #17 to have the bed in lowest position, encouraging non-skid socks and footwear, keeping frequently used items within reach, assisting with transfers as needed and administering medications as ordered. An intervention for a floor mat at bedside while Resident #17 was in bed was initiated on 11/22/24. -However, Resident #17's care plan was not updated after her falls on 1/11/25, 2/3/25 and 2/4/25 (see below). A fall risk evaluation, dated 10/2/24, revealed Resident #17 was at a high risk for falling. A progress note, dated 11/8/24 at 2:33 p.m., revealed Resident #17 was discharged from skilled services with physical therapy. An order for an anti-rollback device for Resident #17's wheelchair was placed due to the resident transferring without asking for assistance because of her dementia. A progress note, dated 11/11/24 at 10:46 a.m. revealed the facility received orders to place an anti-rollback device on Resident #17's wheelchair. -However, review of Resident #17's care plan did not reveal documentation regarding the implementation of anti-rollbacks for Resident #17. 1. Fall incident on 11/17/24 - unwitnessed A fall risk evaluation, dated 11/17/24 at 12:34 p.m., revealed Resident #17 was at a high risk for falling. A progress note, dated 11/17/24 at 4:43 a.m., revealed Resident #17 was found on the floor at 3:45 a.m. by a CNA. Resident #17 had blood on her gown and was bleeding from her head. Resident #17's vital signs and neurological examination were within normal limits. The nurse performing the assessment alerted Resident #17's provider and received orders to send the resident out for evaluation. Resident #17 was transferred to the emergency room at 4:05 a.m. The facility fall report, dated 11/17/24 at 4:28 a.m., revealed Resident #17 was found on the floor with her head underneath her bed. The resident's bed was in the lowest position. The report documented it appeared Resident #17 had been

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents/hazards. Resident #1 had a diagnosis of advanced Huntington's disease (inherited disease that causes degeneration of the nerve cells in the brain) and was identified as a fall risk. Interventions for Resident #1 included a low bed and a fall mat. Resident #1 needed the assistance of two staff for transfers. On the morning of [DATE], certified nurse aide (CNA) #1 was assisting Resident #1 to get ready for the day. CNA #1 had lifted the bed from a low position to a higher position and had removed the fall mat to prepare to transfer Resident #1. CNA #1 stepped away from Resident #1 with the bed in a high position and left the room to find assistance for the transfer. While CNA #1 was away from Resident #1, she fell out of bed and was found on the floor lying on her right arm with the right side of her face against the floor. Blood was visible around Resident #1's head. Resident #1 was sent out to the hospital and received sutures to her right temple and was noted to have a sacral fracture. Resident #1 passed away on [DATE]. According to the death certificate the cause of death was decomposition following a mechanical fall. Findings include: I. Resident status Resident #1, age [AGE], was admitted on [DATE], readmitted on [DATE] and passed away on [DATE]. According to the [DATE] computerized physician's order (CPO), diagnoses included Huntington's disease and abnormal involuntary movements. The [DATE] minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) of zero out of 15. The assessment identified a diagnosis of a progressive neurological condition. Resident #1 was identified as receiving hospice care. II. Fall on [DATE] The facility investigation dated [DATE] at 7:53 a.m. described the incident as, The CNA was providing care to the resident. The CNA stepped out of the room to ask for assistance to transfer the resident. the resident rolled out of the bed sustaining injury. The resident plan of care included an air mattress with winged overlay for sensory perception. The conclusion to the investigation documented, The staff member did not have a history of this type of incident. Staff member was providing care services to the resident and left the room to get a second staff member to assist with the transfer- the resident had a recent medication change causing her to be more alert. This is an educational opportunity to press the call light when extra assistance is needed and not to step out of the room. The fall investigation and progress note, dated [DATE] at 8:00 a.m., noted CNA #1 notified the nurse that the resident had fallen out of bed. The nurse immediately entered the room finding the resident lying on her right arm with the right side of her face against the floor. Upon examination, the nurse and the charge registered nurse (RN) found Resident #1 had a large hematoma to the right temple area which was bleeding. Her entire head was examined but no other injury was noted due to the blood and her hair. Her vital signs and neurological assessment were completed immediately. The area was cleaned immediately and pressure was applied to her right temple until the ambulance arrived. Her family and medical doctor (MD) were notified by the assistant director of nursing (ADON). III. Record review The care plan, initiated [DATE] and revised [DATE], identified the resident required assistance with self-care deficits including dressing and impaired physical mobility secondary to Huntington's disease. Interventions included transfers with a Hoyer lift with two or more staff as she allowed. The anticoagulant care plan, initiated [DATE] and revised [DATE], identified a risk for bleeding related to the use of an antiplatelet. Interventions included to notify physician of any problems or concerns. The fall care plan, initiated on [DATE], identified the resident had an active history of falls related to weakness. Interventions included: -Assist with transfers/ambulation as needed. -Call light within reach when possible. Another fall care plan, initiated [DATE] and revised on [DATE], identified a history of falls. Interventions included: -Assist with transfers/ambulation as needed. -Keep call light in reach. -Notify physician of any changes in condition. -Resident to have a soft helmet on at all times while in bed and hard helmet on while out of bed. -Helmet for safety related to unsteady gait/balance related to Huntington's disease. -Winged mattress for sensory perception. Fall intervention related to overestimating when transferring in and out of bed. -Encourage floor mat next to bedside when the resident is laying in bed. The care plan, initiated [DATE] and revised [DATE], identified limited physical mobility related to Hintington's disease. Interventions included the resident was totally dependent on staff for locomotion. The care plan, initiated [DATE] and revised [DATE], identified a communication related to impaired cognition. Interventions included to ensure/provide a safe environment, call light in reach, adequate low glare light, bed in lowest position and wheels locked and to avoid isolation. She was admitted to hospice care on [DATE] for Huntington's Disease. The provider follow-up note dated [DATE] included history of falls: continue with helmet when out of bed and fall mat at bedside for safety. The progress note dated, [DATE] at 8:05 a.m., identified the facility called and notified the hospice provider of the fall with a hematoma on the right side of the head with difficulty controlling the bleeding. An order to send the resident to the emergency room (ER) for evaluation. The progress note dated, [DATE] at 8:22 a.m., included a message was left with the resident's daughter. The facility explained the resident had a fall with a head laceration to the right temple with bleeding. The progress note dated, [DATE] at 2:16 p.m., included the report from the hospital that the resident received six sutures to the head laceration and would need to keep pressure bandage on for at least the next 24 hours. The resident was found to have a sacral fracture. The hospice provider was notified about the update. The provider progress note dated, [DATE] at 1:53 a.m., included Patient found resting comfortably in bed. She has head wrapped with pressure bandage due to a recent fall with head laceration. Was treated in emergency room and returned to the facility. Continues under hospice care. The provider follow-up note dated [DATE] included history of falls: continue with helmet when out of bed and fall mat at bedside for safety. The provider progress note, dated [DATE] at 4:15 a.m., included in part, appears comfortable. Patient with sutured area on forehead. The interdisciplinary team (IDT) fall risk note, dated [DATE] at 8:31 a.m., included Related to resident rolling out of bed on [DATE]. Soft helmet while in bed and hard helmet when out of bed for safety related to weakness of body movements from disease process of Huntington's disease. The hospice note dated, [DATE] at 1:10 a.m., included the patient was in her bed in the low position. The note included discussion of status with risk of a brain bleed was possible. Interventions provided included fall precautions to include a low bed and call light in place. The hospice note, dated [DATE] (time unknown), included the nurse left the patient's room with the patient lying supine and helmet on, call light in reach, and fall mat in place on the floor next to the bed. The facility investigation, dated [DATE] at 11:30 p.m., described the incident, resident passed away peacefully with family at bedside under hospice care. The conclusion to the investigation documented, the resident passed away peacefully. Resident was without brain injury from fall 8 (eight) days prior. Facility concluded resident expired due to Huntington's disease process. The death certificate for Resident #1 identified the date of death as [DATE]. The cause of death was identified as decompensation following a mechanical fall, hypovolemia (low blood volume), and cephalohematoma (blood under the scalp from an injury). The death certificate was signed on [DATE]. IV. Interviews CNA #1 was interviewed on [DATE] at 1:05 p.m. CNA #1 said staff would check with their supervisor when they arrived to see which residents were fall risks and on fall precautions/interventions. He said if the resident had a fall mat they automatically knew there were fall interventions for the resident. He said every resident on fall precautions had a fall mat and repositioning pillows. He said if someone had a fall they were to notify the nurse immediately after making sure the resident was safe. He said if a resident required the assistance of two people, staff were to use the call light and wait for assistance and never to leave the resident unattended. He said if a resident had a fall after the nursing assessment they were to be monitored every 15 minutes. CNA #2 was interviewed on [DATE] at 1:10 p.m. CNA #2 said she would know who was a fall risk from the medical record on kiosks and the fall mats next to the bed. She said there were checklists that identified specific needs of the resident. She said the information in the kiosk had the resident specific fall interventions. She said if a resident were to fall she was to make sure the resident was safe and call for a nurse to assess. She said if she needed assistance from another staff member she was not to leave the resident alone but she was supposed to use the call light and wait for assistance. RN #1 was interviewed [DATE] on 1:15 p.m. RN #1 said the fall interventions for each resident were in the physician's orders. She said if a resident fell, the CNAs were to call her or any nurse and the nurse who completed the initial assessment would complete an assessment, fill out a fall risk assessment and notify the director of nursing (DON). She said if the injury was severe, she would send out the resident. The DON was interviewed on [DATE] at 1:35 p.m. The DON said the Resident #1 had fallen from the bed that was not in the low position and the fall mat was not in place when CNA #1 had stepped out to get assistance with the transfer. She said the resident had fallen and hit her head on the floor and sustained a laceration to the right temple. She said the facility sent her out to the ER and made notifications to the hospice provider, the family and the physician. She said the hospital reported to the facility the laceration needed six sutures and to keep the pressure dressing on for 24 hours. The DON said CNA #1 acknowledged she failed to follow facility protocol and left a resident identified as a fall risk unattended which resulted in the resident falling out of bed. She said the resident passed away eight days after her fall. She said after the fall, the facility provided education on assistance with transfers. She said the CNAs had access to the fall interventions on the [NAME] (a tool utilized by staff for providing consistent care for residents) that could be accessed by the kiosk. The nursing home administrator (NHA) was interviewed on [DATE] at 2:45 p.m. The NHA said CNA #1 was terminated after the incident. The hospice executive director ([NAME]) was interviewed on [DATE] at 4:45 p.m. The [NAME] said hospice assessed the resident after notification of the fall and when the resident returned to the facility. She said the facility called hospice about the fall and bleeding and the ER transfer on [DATE]. She said the resident had trauma to the right temple which required six sutures. She said the coroner's death certificate identified the cause of death as decomposition following a mechanical fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure two (#1 and #7) of five residents received services and assistance to prevent a reduction in range of motion out of 23 sample residents. According to diagnoses on admission, Resident #1 did not admit to the facility with a contracture to her left hand but based on observations and interviews on 7/24-7/26/23, the resident was unable to extend her fingers independently and/or without pain. The facility failed to provide the resident interventions to prevent a reduction in the resident's range of motion of her left hand. Further, the facility failed to provide the resident occupational therapy (OT) as ordered after the identification of a possible ligament injury to the left wrist on 1/16/23. The facility's failure to provide services to maintain the resident's mobility contributed to a decline in the mobility of the resident's left wrist and hand. Resident #7 was ordered assistance with hand splinting from the facility staff post surgical revision of her left hand. Interview and record review revealed the facility failed to ensure the resident was receiving assistance as ordered 3/14/23, 3/16/23, 3/25/23, 4/4/23, and 5/4/23, to maintain mobility or decrease further loss of range of motion of the resident's left hand. Findings include: I. Resident #1 A. Resident status Resident #1, age [AGE], was admitted to the facility on [DATE]. According to the July 2023 computerized physician's orders (CPO), diagnoses included diabetes type II, dementia with agitation and disorders of bone density and bone structure. The 6/23/23 minimum data set (MDS) assessment showed the resident had significant cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required extensive one-two person physical assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. The resident had no functional limitations in range of motion of her upper or lower extremities. She was enrolled in hospice and had not received any therapy or restorative services during the MDS look back period. -No diagnosis of arthritis or cellulitis (bacterial infection to the skin) was indicated. B. Resident observations The resident was observed on 7/24/23 at 10:48 a.m. inside the activity room. The fingers on resident's left hand were curled and while participating in a balloon catch activity, the resident was unable to open her left hand at all. Resident #1 was observed on 7/25/23 at 12:15 p.m. in the lunchroom. The resident was attempting to adjust the front of her shirt with her left hand but she was only able to pinch the material with her thumb. Her left hand remained curled into a fist. Resident #1 was observed on 7/26/23 at 12:16 p.m. in the lunchroom. She was able to feed herself using her right hand but was not able to use her left hand. Her left hand rested on her lap, fingers curled in a fist position. C. Record review The comprehensive care plan initiated on 7/21/21 revealed the resident had a history of cellulitis in her left hand. Interventions were to assist the resident to the bathroom as needed, offer non medicinal means of pain relief, encourage the resident to comply with recommended interventions to help prevent skin breakdown, and notify the medical director or hospice of any skin breakdown. The resident had decreased range of motion with interventions to keep the call light within reach and keep frequently used items in reach. -The care plan did not indicate the reason, the location of, or the extent of the resident's decreased range of motion. The CPO reviewed from 7/17/22-7/26/23 revealed: -X-ray of left wrist due to red, swollen and warm-ordered on 7/17/22. -Keflex 500 milligram (MG])- give one tablet by mouth four times a day for cellulitis for five days-ordered on 7/18/22. -Voltaren gel 1%- apply to left wrist topically two times a day for joint pain and swelling for two weeks-ordered on 9/6/22. -Keflex 500 MG- give one tablet by mouth four times a day for cellulitis in the left hand for five days-ordered on 9/3/22. -Voltaren gel 1%- apply to left wrist topically two times a day for arthritic pain for two months-ordered on 9/27/22. -Aspercreme lotion 10%- apply to left wrist topically every eight hours as needed for pain- ordered on 10/28/22. -Occupational therapy (OT) to evaluate and treat for decreased range of motion and use of left upper extremities-ordered on 10/24/22 and discontinued 12/5/22. -OT to continue with therapy three times a week for thirty days related to wheelchair management, self-care training, therapeutic activities, therapeutic exercises and manual techniques due to lack of coordination and muscle weakness dated 10/26/22 and discontinued 2/6/23. -Restorative therapy for active assistive range of motion with rod; shoulder and elbow flex extension three times weekly or as tolerated- ordered 1/4/23 and discontinued 3/15/23. -X-ray of left hand and fingers for swelling and pain-ordered on 1/11/23. -Voltaren gel 1%- apply to left hand and knuckles topically two times a day for pain- ordered on 1/11/23. -OT to evaluate and treat diagnosis of left wrist scapholunate (small bones in the wrist) ligament injury- ordered on 1/16/23. -Voltaren gel 1%- apply to left hand and knuckles topically every six hours as needed for pain- ordered on 1/20/23. -No further orders were located pertaining to the resident's left wrist or hand. Physician visit notes dated from 9/27/22 to 1/17/23 revealed: -Physician visit note dated 9/27/22 revealed the reason for the appointment was for a swollen left wrist and left hand. The resident was able to hold objects in her left hand and still maintained range of motion. Voltaren gel was continued daily for joint arthropathy (disease of the joint). -Physician visit note dated 10/21/22 revealed the reason for the appointment was due to an abnormal reduction of circulating white blood cells. During the visit, the physician noted the nurses reported the resident was displaying signs of pain and discomfort with no recent falls or specific areas of concern identified. The resident was unable to describe the pain. The resident was still able to move all four extremities however, chronic arthritic changes were noted by the physician. -Physician visit note dated 1/11/23 revealed the reason for the appointment was left hand pain and swelling. The resident presented with acute pain, redness and swelling to her left hand and knuckles. She had a history of arthritis in her left wrist. An x-ray of the left hand was ordered to rule out any possible injuries and a topical gel was provided for relief of pain and swelling. -Physician visit note dated 1/12/23 revealed the reason for the appointment was left hand pain and swelling. The swelling had improved but the joints remained tender to the touch. At this time, the note documented the resident was l able to open her left hand and perform a range of motion activities but with discomfort. -Physician visit note dated 1/16/23 revealed the reason for the appointment was left hand pain and x-ray results. The x-rays revealed soft tissue swelling and arthritic changes of the hand with a suspected injury to the ligaments in the small bones of the resident's left wrist. The swelling had resolved but the resident was still displaying discomfort with her range of motion in the left wrist. A referral was recommended for OT to treat and evaluate the ligament injury. Review of therapy notes revealed: An OT therapist plan of care notes dated 11/23/22 revealed the resident was being seen for cellulitis of the left upper limb. The resident's level of functioning was bilateral upper extremity functional activity tolerance with moderate cues for left upper extremity use, no reported pain. The goal was for the resident to be able to feed herself with finger foods and use a cup to drink with stand by assistance from a therapist. The underlying impairments documented were decreased strength and range of motion in the left upper extremity requiring moderate assistance from staff. The OT therapist discharge notes dated 12/22/2 revealed the resident was able to feed herself with finger foods and use a cup to drink with verbal cues provided by staff. The goal of increasing strength and range of motion in the left upper extremity was not met due to resident pain. Record review failed to reveal a comprehensive assessment of the resident's range of motion by physical or occupational therapy since the resident's admission in July 2021, since resolution of her left wrist cellulitis in the fall of 2022, or since x-rays revealed ligament damage in 1/16/23. Further, record review revealed no evaluation or treatment recommendations from OT following the physician order on 1/16/23 for a referral to OT to treat and evaluate the ligament injury. Progress notes dated from 1/17/23 to 7/27/23 revealed the resident received restorative services to maintain mobility; however, there was no documentation regarding exercises for or the resident's mobility of her left wrist and hand. -Restorative therapy note dated 1/19/23 revealed the restorative therapist was working with the resident three times a week on upper body exercises to build up strength. -Restorative therapy note dated 1/26/23 revealed the resident was stable with restorative. She did refuse to participate at times but the restorative therapist would continue to encourage her to participate. -Restorative program note dated 2/2/23 revealed the resident remained stable with the restorative therapist's encouragement. -Restorative therapy note dated 2/10/23 revealed the resident continued with the restorative program and was totally physically dependent on the restorative therapist to perform all exercises. -Restorative therapy note dated 2/14/23 revealed the resident continued with the restorative program to work on upper body range of motion to prevent decline. -Restorative therapy note dated to 2/16/23 revealed the resident continued to refuse to participate at times and required restorative therapist encouragement. -Restorative therapy note dated 2/23/23 revealed the resident continued to work with the restorative therapist three times a week. She continued to receive encouragement to participate. -Restorative therapy note dated 3/2/23 revealed no changes to the resident's exercise program and she required total physical assistance from the restorative therapist to participate. -Nursing note dated 3/30/23 revealed the resident had been newly admitted to hospice services for a diagnosis of Alzheimer's disease. -There were no notes located after 3/22/23 referring to the status or treatment of the resident's left wrist and hand arthritis. D. Interviews and observation CNA #9 was interviewed on 7/26/23 at 9:45 a.m. She stated Resident #1 had a contracture to her left hand and she did not have a brace or hand splint. CNA #9 stated she did not know if occupational therapy or restorative therapy were working with Resident #1. Certified occupational therapy assistant (COTA) #1 was interviewed on 7/26/23 at 12:00 p.m. He said occupational therapy had worked with Resident #1 from 10/25/22 to 12/22/22. One of the goals was to strengthen the left upper extremity. Resident #1 had an incomplete range of motion in the left hand but it was not contractured at that time. He was not aware of the recommended referral from the physician on1/16/23. (See above) The minimum data set coordinator (MDS) was interviewed on 7/27/23 at 12:00 p.m. She stated she was also the restorative therapy nurse. She said she had not worked with Resident #1 since she enrolled in hospice services on 3/30/23. Restorative had worked with her on upper extremity strength and range of motion. She could not recall if Resident #1 had a contracture in her left hand when she was discharged from restorative therapy services in March. The hospice aide (HA) was interviewed on 7/27/23 at 12:30 p.m. She was taking Resident #1 down the hallway and attempted to open the resident's left hand during the interview. The resident was unable to open any of her fingers without the HA's assistance and without grimacing and showing signs of pain. The HA stated it was very painful for the resident to try to open the left hand when she tried to clean the inside of the hand during showers. She said the hand was always closed when she came to see the resident and she had not seen any intervention in place to manage the contracture. The director of nursing (DON) was interviewed on 7/27/23 at 1:40 p.m. The DON was unaware Resident #1 had a contraction to her left hand, did not know what treatment the resident was receiving and did not know the status of her range of motion. The hospice clinical director (HCD) was interviewed via phone on 7/27/23 at 1:21 p.m. She stated she did not see anything in the resident's hospice records regarding her left hand. If there was a decline related condition, like a hand contracture, it would be documented in the hospice records if it occurred while the resident was on hospice services. II. Resident #7 A. Resident status Resident #7, age [AGE],was admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included diabetes type II, contracture of the left hand (dated 4/2/23), fibromyalgia, bipolar disorder, chronic pain syndrome and injury of extensor muscle, fascia and tendon of left ring finger (dated 2/21/23). The 5/10/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive two person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. She required total assistance for bathing and locomotion. The resident had not received any orthopedic surgery to repair bones, tendons, or ligaments in hand. The resident had an upper extremity impairment on one side limiting range of motion. The resident received occupational and physical therapy three times in the seven day lookback period. B. Resident observation and interview Resident #7 was interviewed on 7/26/23 at 9:30 a.m. She stated she had surgery on her left hand in January 2023 and was supposed to be doing therapy but therapy did not help her learn how to put a hand splint on and off on her own. She said she needed the staff's help but they did not do it for her except for maybe one time a week. Her splint was observed on her table next to her TV. Resident #7 was observed on 7/26/23 at 9:30 a.m. Two of the fingers on her left hand appeared bent over and the resident, when asked, was not able to open them. C. Record review The comprehensive care plan revised on 6/21/23 revealed the resident had a surgical repair of the left ring finger related to trigger finger type stiffening. Interventions included applying topical treatments as ordered and administering medication as ordered. The resident required assistance with self-care deficits related to a trigger finger surgical procedure due to tendon pain and to help decrease contracture like range of motion. Interventions were for staff to provide a level of assistance as required and to set up items needed within the residence reach. -The care plan did not include the use of a hand splint. The CPO reviewed from 12/1/22 to 7/26/23 revealed: -Surgical revision appointment for left hand on 12/7/22 at joint clinic- ordered on 12/1/22. -Post operative instructions from the surgical center to keep the operative hand elevated and watch for signs of infection- ordered 12/7/22. -X-ray to left wrist for pain- ordered on 1/30/23. -Physical and occupational therapy to evaluate and treat with no directions specified for order- ordered on 2/4/23 and discontinued 3/6/23. -Order from physician requesting occupational therapy (OT) for hand activities of daily living needs-ordered on 3/10/23 and discontinued on 7/3/23. -Physical therapy (PT) to evaluate and treat five times a week for twelve weeks for therapeutic activities, therapeutic exercises, neuromuscular reeducation related to muscle wasting- ordered on 2/8/23 and discontinued 6/15/23. -Order for OT for hand activities of daily living needs- ordered on 3/10/23 and discontinued on 7/3/23. -Order for splint replacement: remove to let resident move finger and retape each shift- ordered on 3/16/23 and discontinued 3/25/23. -Order for splint replacement: remove to let resident move finger and retape tape each shift- ordered on 3/25/23 and discontinued 5/4/23. -Occupational therapy for the resident to continue with occupational therapy services for 12 visits in 30 days for self-care, wheelchair management, and splinting- ordered on 4/4/23 and discontinued 5/4/23. -Physician order to use left hand brace (splint) 2 hours a day- ordered on 5/4/23 with no end date. -Occupational therapy order to evaluate and treat for left hand trigger finger ordered on 7/24/23. -Occupational therapy for the resident to be seen three times a week for four weeks for diagnosis of self-care, wheelchair assessment, and short arm splint- ordered on 7/24/23. Physician records reviewed from 3/14/23 to 7/26/23 revealed: -Physicians order dated 3/14/23 from the bone and joint clinic for physical therapy two to three times per week for four to six weeks. Finger splint to be applied to the left ring finger to aid in extension related to deformity of left ring finger. -Physician follow-up note dated 3/14/23 revealed the resident had seen the hand surgeon that day and was placed on a finger splint with instructions to tighten with tape daily to help with contracture of 4th digit. -The certified nurse aide (CNA) facility tasks for July 2023 did not reveal instructions to assist the resident with putting on or removing a hand splint. Further, review of the resident's treatment records did not document the implementation of current splint orders. Restorative progress notes revealed one note, dated 6/30/23, that read the restorative CNA washed the resident's left hand and was able to put her hand splint on for one to two hours. D. Staff interviews Registered nurse (RN) #1 was interviewed on 7/26/23 at 9:10 a.m. She said Resident #7 had a contracture to her left hand and had a hand splint staff were to assist her with. CNA #9 was interviewed on 7/26/23 at 9:45 a.m. CNA #9 did know if Resident #7 had a hand brace or splint. Certified occupational therapy assistant (COTA) #1 was interviewed on 7/26/23 at 12:00 p.m. He stated the therapy department had just met with Resident #7 to initiate occupational therapy for her left hand at her request. He stated she had a hand brace but she was incapable of using it without staff assistance. The minimum data set coordinator (MDS) was interviewed on 7/27/23 at 12:00 p.m. She stated she was also the restorative therapy nurse. She said Resident #7 was receiving restorative therapy services from 5/25/23 until 7/3/23. Restorative was working with the resident on range of motion to promote extension of fingers on the left hand. She was working with Resident #7 on putting on a hand splint. The DON was interviewed on 7/27/23 at 1:40 p.m. She said was aware Resident #7 had a contracture in her left hand but did not know if there was a splint ordered for the resident to wear.

Based on record review and interviews, the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to unavailable and missed medications that rose to the scope and severity of immediate jeopardy during the survey on 7/24/23 to 8/14/23. Due to the missed medications, it caused distress and decline to Resident #7 and Resident #25. Findings include: I. Facility policy The Quality Assessment Performance Improvement Plan, dated 4/3/23, was provided by the nursing home administrator (NHA) on 7/24/23 at 1:00 p.m. It revealed in pertinent part, Our facility's QAPI plan serves as guide for our overall quality improvement program and initiatives. The decision making within the facility will be driven by quality assurance performance improvement principles. These decisions will assist in promoting quality of care and quality of life of residents. In addition, these principles will lead to an emphasis on resident choice, person directed care and resident transitions. Any system that affects the satisfaction of residents, families and associates will be considered an area of opportunity. This will include systems affecting the quality of care, quality of life and safety of residents. Our QAPI efforts and activities across departments in order to better work together in assuring that areas of concern are being addressed and services are continually improved. The facility provides care and services to residents across the continuum of care. Because these services have an impact on the clinical care of the resident, all departments will be involved in QAPI efforts to continuously improve the clinical care provided. QAPI efforts will also incorporate healthcare partners in order to provide safe, effective care transitions to the residents we serve. These efforts are established in order to continuously improve our services. The QAPI program at this facility is comprehensive, data-driven and involves the full range of care and services offered, including the full range of departments. QAPI principles are utilized in order to align business and clinical care decisions within the facility in order to provide residents with individualized care to meet their specific goals. II. Cross-reference citation Cross-reference F760: The facility failed to ensure Resident #7 had medication available to include vital medications and Resident #25 received all medications as ordered by the medical provider. The facility failed to ensure medications were available for Resident #7 on several occasions including during the recertification process. The facility failed to administer medications to Resident #25, citing the resident was sleeping but failed to notify the providers of the several missed doses. The facility's failure to ensure Residents #7 and #25 received their medications as ordered contributed to Resident #7 experiencing increasing distress (fear, anxiety, behavioral symptoms) and Resident #25 experiencing signs of distress (agitation, behavioral symptoms). The facility's failure to develop, implement, and monitor medication administration processes to prevent repeated, significant medication errors contributed actual decline in Resident #7 and #25's quality of life and created the potential for serious physical and psychosocial harm if the situation was not immediately corrected. III. Interviews The director of nursing (DON) and the NHA were interviewed on 8/14/23 at 11:40 a.m. The DON said the missed medications for Resident #7 due to unavailability was investigated and narrowed down to one nurse. She said education was provided by the facility to include the DON and the facility reaching out to the pharmacy consultant to help with education as well. When the facility discovered the medication was still not being administered due to unavailability for Resident #7, they terminated the nurse on 7/11/23. She said she was aware the issue was still occurring during the recertification survey. The DON said the facility knew of non-compliance with the medication pass and educated the nurses on the importance of the medication and the process of ordering medications to prevent running out of the medication. The DON said she did not consider the medications for Resident #25 missed doses. She said the resident had the right to sleep. She said when the nurse documented sleeping it was considered acceptable documentation. She said the doses not given when the resident was sleeping were not communicated with the provider. The DON said as of 8/14/23, the facility was current on notification to providers of missed medications. The DON said the plan going forward was she would implement ordering medications that qualified for auto-refill and until it happened she or a designee would check the medication carts weekly to ensure a minimum of a seven day supply to help prevent future missed doses due to unavailability. She said there would be a review of residents who sleep during medication administration times and contact providers to discuss the medication orders.