**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to act upon a change of condition for one of 28 sampled residents (R) (263) related to low blood sugar, which resulted in being transferred to the hospital for treatment. This failure to provide quick intervention led to harm being identified on 12/29/2023, when R263's blood sugar went so low, to the point where the resident was unresponsive and slow to respond to the emergency use of Glucagon intramuscular when administered at the facility. R263 had to be transferred to the emergency room (ER). Findings included: 1. A review of the electronic medical record (EMR) revealed that R263 had been admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus. A review of R263's quarterly Minimum Data Set (MDS) assessment with an assessment Reference Date (ARD) of 12/6/2023 indicated a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated R263 was severely cognitively impaired. R263 was also coded as taking Hypoglycemic medication, insulin, while a resident at the facility. A review of R263's care plan revealed a care plan dated 10/20/2023 which indicated, I have a diagnosis of Diabetes Mellitus [sic]. Interventions were Diabetes medication as ordered by doctor [sic]. Monitor/document for side effects and effectiveness . Monitor/document/report PRN [as needed] any s/s [signs/symptoms] of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait [sic]. A review of R263's Blood Sugars revealed documentation on 12/29/2023 at 10:04 am of having a blood sugar reading of 45 milligrams per deciliter (mg/dl). The EMR was reviewed in its entirety, and no documentation of the nurses' response to the low blood sugar was identified. A review of the facility's undated Blood Sugar Protocol indicated, If BS [blood sugar] < [less than]60 and asymptomatic, treat with 15 mg [milligrams] of oral glucose. If symptomatic (confusion and/or inability to swallow), treat with IM [intramuscular] Glucagon 1 mg. Recheck BS in 1 hour. If BS > [greater than] 60, continue to monitor. If BS still <60 notify MD [medical doctor] [sic]. A review of the progress notes dated 12/29/2023 at 12:05 pm, written by the Nurse Practitioner (NP)1 indicated, .Patient seen for nurse reports of lethargy. Patients are noted to be unresponsive. Glucose level 39, nurse reports unknown last baseline, reports patient was not able to take meds [medicines] this am d/t [due to] lethargy. Oral glucose was attempted, but the patient was too unresponsive. Glucagon IM given; patient still poorly responsive . Gen: Unresponsive, diaphoretic . Resp [Respirations]: Irregular breathing . Hypoglycemia unawareness due to type 1 diabetes mellitus, unknown down time, poorly responsive to glucagon. Send to ER for full eval [evaluation] . A review of the hospital records revealed [R263] was found unresponsive at [name of nursing facility] this morning and noted to be hypoglycemic with blood glucose of 30. EMS [Emergency Medical Services] was called, she [R263] received glucagon and D50 with improvement to 67 and improvement in mentation. She [R263] presented to the ED [emergency department] and a recurrent episode of hypoglycemia after initial improvement, and this improved again with dextrose and juice . During an interview on 3/18/2025 at 2:24 pm, Licensed Practical Nurse (LPN)1 stated, I must have done something because that [blood sugar] is too low. I must have forgotten to document it. During an interview on 3/21/2025 at 3:00 pm, NP1 stated, That was a while ago, and I don't remember anything except what I had documented. During an interview on 3/21/2025 at 4:30 pm, the Interim Director of Nursing (DON) stated, I would expect the nurses to follow the Blood Sugar Protocol if they obtained a low blood sugar and notify the doctor of what had occurred and what treatment had to be given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of Centers for Medicare and Medicaid (CMS) guidance, and policy review, the facility failed to ensure that one resident (R) (R#48) of three residents reviewed for pressure sores who was at risk for pressure ulcer development did not develop a pressure ulcer and received the treatment needed to promote healing. R#48 was re-admitted to the facility post hospitalization on 1/7/22 with skin issues which deteriorated to a Stage III pressure ulcer with signs of infection. The facility failed to conduct weekly assessments, change treatments when the pressure ulcer did not respond, and did not provide treatment in a manner designed to promote healing. This deficient practice harmed the resident and caused localized infection, tissue loss, and pain. Findings include: Review of the facility's Administrative Policy and Procedure titled Pressure Injury Prevention and Management, dated May 2018, revealed that, Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device .Licensed nurses will conduct a skin assessment on all residents upon admission/readmission, weekly, and as needed. Findings will be documented in the medical record . Assessments of pressure injuries will be performed by a licensed nurse and documented in the medical record. Interventions for Prevention and to Promote Healing: a. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury . c. Evidenced-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present . i. Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue. Per CMS's RAI Version 3.0 Manual, Section M1040: Other Ulcers, Wounds and Skin Problems states, Definition Moisture Associated Skin Damage is superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration .M1040H Moisture Associated Skin Damage (MASD). MASD is also referred to as maceration and includes incontinence-associated dermatitis, intertriginous dermatitis, peri wound moisture-associated dermatitis, and peristomal moisture-associated dermatitis. Moisture exposure and MASD are risk factors for pressure ulcer/injury development. Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown. MASD without skin erosion is characterized by red/bright red color (hyperpigmentation), and the surrounding skin may be white (hypopigmentation). The skin damage is usually blanchable and diffuse and has irregular edges. Inflammation of the skin may also be present. MASD with skin erosion has superficial/partial thickness skin loss and may have hyper or hypopigmentation; the tissue is blanchable and diffuse and has irregular edges. Inflammation of the skin may also be present. Necrosis is not found in MASD. If pressure and moisture are both present, code the skin damage as a pressure ulcer/injury in M0300. If there is tissue damage extending into the subcutaneous tissue or deeper and/or necrosis is present, code the skin damage as a pressure ulcer in M0300. Review of R#48's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R#48 was admitted to the facility on [DATE] for long term care. Review of R#48's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/3/22 revealed R#48 had an unplanned discharge to the hospital and was expected to return. At the time of the transfer to the hospital, the resident had no skin problems. Review of R#48's admission Nursing Evaluation dated 1/7/22 under the Assessments tab in the EMR and documented by Licensed Practical Nurse (LPN)1 revealed the resident was re-admitted from the hospital. Review of the evaluation completed upon readmission to the facility revealed that LPN1 documented the resident had skin issues upon re-admission; however, there was no documented evaluation of the skin issues (i.e. no description of the skin issue, including type of issue, location, physical appearance including size, color, and stage, if appropriate.) Review of R#48's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/22 documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated the resident had moderate cognitive impairment. The MDS documented the resident was at risk for developing pressure ulcers, had MASD, and required the use of pressure reducing devices for the bed and chair and application of ointments. Although the 1/12/22 MDS documented the present of MASD, review of R#48's clinical record revealed that there was no documentation in the EMR from 1/7/22 to 1/12/22 of the presence of MASD. Review of a 1/17/22 nursing Progress Note in the Progress Notes tab in the EMR revealed the resident had a 3 cm [centimeter] breakdown area on the right buttock located near the sacrum area. Cleaned wound, applied zinc oxide to the area, and dressed with border dressing. There was no further evaluation that included complete measurements and identification of the wound. In addition to the skin breakdown to right buttock/sacrum, review of R#48's Skin/Wound Note dated 1/20/22 by the Wound Care Nurse (WCN) revealed the resident also had, excoriation to left ischium 3 x 4 cm. area clean with NSS [normal saline solution], and duoderm [occlusive, waterproof dressing for dry to lightly exuding wounds] dressing applied. Excoriation to sacral area 2 x 2 cm. area clean with NSS, pat dry, zinc oxide applied. Resident denies discomfort. Resident place on [Wound Physician] list for evaluation. Although the facility policy called for weekly skin assessments, there was no further documentation of the left ischium site wound or evidence that the wound was resolved. Treatment orders remained active as of the date of the survey and were administered per the Medication/Treatment Administration Records. Review of the Wound Physician (WP) Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 1/28/22 revealed that R#48 now had a full thickness wound of the right buttock that measured 3 cm length (L) x 3 cm width (W) x 0.1 cm. depth (D) with light serous exudate with 30% slough (a mass of dead tissue separating from an ulcer) and 70% granulation (pink tissue containing new connective tissue that is part of the healing process). The physician performed a surgical debridement to 2.7 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1 cm and healthy bleeding tissue. The WP diagnosed MASD with a treatment of daily zinc ointment dressing changes. The goal for this wound was for healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 21 days. This estimate is made with an 80% degree of certainty. Although facility policy called for weekly skin assessments, review of the EMR revealed no evidence of wound evaluations in the EMR from 1/28/22 until 2/15/22 by either the Wound Physician or licensed nursing staff. Review of the Wound Physician (WP) Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 2/15/22 documented a full thickness wound of right buttock measuring 4 cm L x 3 cm W x 0.1 cm. D with moderate serous drainage, 30% slough, and 70% granulation. The summary documented there was no change in the wound progression. The WP documented that he surgically excise [sic] 3.6 cm of devitalized tissue including slough, biofilm [a thin, slimy film of bacteria that adheres to a surface] and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Treatment Alginate Calcium w/silver with border dressing. Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 2/21/22 documented that the visit for that day was rescheduled and there was no wound evaluation documented by either the Wound Care Physician or licensed nursing staff in the EMR until 2/28/22 Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 2/28/22 documented a full thickness wound of right buttock healing MASD 5 cm x 3 cm x 0.1 cm with moderate serous drainage, 30% slough, and 70% granulation. There was no change in the wound progression. The WP surgically excised 4.5 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Although there was no progression in wound healing, the treatment was not changed and the orders for the Alginate Calcium with silver dressing continued. There were no wound evaluations, per facility policy, from 3/1/22 to 3/17/22 documented in the EMR by either the Wound Care Physician or licensed nursing staff. Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 3/18/22 documented the full thickness right buttock wound measured 5 cm x 5 x 0.1 cm with moderate serous drainage, 30% slough, and 70% granulation with no change in the wound progression. The WP surgically excised 7.5 cm of devitalized tissue including slough, biofilm and non-viable muscle and surrounding fascial fibers were removed at a depth of 0.5 cm and healthy bleeding tissue was observed. Review of orders revealed that the wound treatment remained unchanged, even though the physician documented that there was no change in wound progression. Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 3/21/22 documented a full thickness right buttock wound that measured 3.0 cm x 4.0 x 0.1 with moderate serous drainage, 30% slough, and 70% granulation and improved for the wound progression. The WP excised 3.6 cm of devitalized tissue including slough, biofilm and non-viable muscle and surrounding fascial fibers were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 3/28/22 documented the full thickness right buttock wound measured 4 cm. x 4 cm. x 0.1 cm with moderate serous drainage, 30% slough, and 70% granulation with no change in the wound progression. The WP surgically excise [sic] 4.8 cm of devitalized tissue including slough, biofilm and non-viable muscle and surrounding fascial fibers were removed at a depth of 0.8 cm and healthy bleeding tissue was observed. There was no evidence of consideration of changes to the wound treatment, which had been in place for six weeks, and had not been effective in promoting healing of the wound. Review of each WP Wound Evaluation & Management Summary located in the Miscellaneous tab documented the Coordination of Care as Data and history pertinent to this patient's care were obtained via Nursing Staff, Patient. This patient's care was discussed with another health care provider Nursing Staff Member during this visit. Review of each of these records revealed the Wound Physician only evaluated the right buttock (sacral) wound. There was no evidence that either the Wound Physician or licensed nursing evaluated, on an ongoing basis, the left ischial wound, even though treatment had been ordered and administered since 1/17/22. As part of the survey, wound care was observed. Review of R#48's active Clinical Physician Orders in the Orders tab located in the EMR dated 1/20/22 directed Cleanse left ischium with NSS, pat dry apply duoderm dressing, change every three day and PRN [as needed]. In addition, review of R48's active Clinical Physician Orders in the Orders tab located in the EMR dated 2/16/22 directed Clean right buttock with NSS, pat dry, apply calcium alginate with silver once daily until resolved. During an observation on 3/29/22 at 8:55 a.m., the Wound Care Nurse (WCN) entered R#48's room to perform wound care. LPN/MDS Coordinator 2 was present to assist. After gathering supplies consisting of sterile water, calcium alginate dressing, clean 4 x 4 dressings, and a composite island dressing, the WCN removed the resident's brief. Although review of the Medication Administration Record (MAR) located in the Orders tab in the EMR revealed treatments had been performed as ordered, observation revealed there was no barrier composite dressing in place over the wound. Observation of the full thickness right buttock (sacral) wound, which was depressed with denuded skin in the center revealed it was the approximate size of a half dollar with yellow and brown/black slough and was surrounded by a large pink/red peri wound. During the observation at 9:12 a.m., the WCN acknowledged that there was no dressing on the wound, stating that that the dressings probably fell off and the CNAs should have informed the nurse so the dressings could have been immediately replaced. The WCN used sterile 4 x 4 dressings soaked in the sterile water to cleanse the outer peri wound area; however, the nurse did not cleanse/irrigate the center of the wound bed. During the task, R#48 said Ow, and acknowledged the wound was painful. R#48 then told the WCN to finish the wound care without pain medication, stating she would be all right. The WCN placed one DermaGinate (a primary dressing for wounds with moderate to heavy exudate such as pressure injuries, diabetic ulcers, post-operative wounds, leg ulcers, donor sites, lacerations, and abrasions.) 2 x 2 sterile dressing flat on top of the peri wound. Observation revealed the nurse failed to use her hands to depress the dressing on the center of the wound bed to make contact then covered it with the composite island dressing (wound covers that combine physically distinct components into a single product to provide multiple functions such as a bacterial barrier, absorption, and adhesion.) During an interview on 3/29/22 at 9:24 a.m., the WCN initially stated that she cleansed the wound with normal saline and applied the calcium alginate as the physician ordered. However, when the WCN checked the supplies in the treatment cart which only contained sterile water containers, she acknowledged that she used sterile water because that's what we have. She confirmed that the physician order directed staff to clean the wound with normal saline, pat dry, and apply calcium alginate. The WCN acknowledged that center of the wound was deeper and stated she did not irrigate the center of the wound because the Wound Physician did not give orders to perform wound irrigation. During an interview on 3/30/22 at 3:35 p.m., the Director of Nursing (DON) expressed the belief that R#48 did not have a pressure ulcer, stating that the resident had MASD and that R#48 was being treated and evaluated weekly in accordance with facility policy by a Wound Physician and the facility's WCN. During an interview on 3/30/22 at 5:33 p.m., R#48's Nurse Practitioner (NP) stated that she leaves the weekly evaluations to the WP. The NP stated that she had never performed an examination of the resident's wounds and stated that if the WP was not available to perform the weekly evaluation, then the WCN should perform the weekly evaluation. During an interview on 3/30/22 at 5:16 p.m., the WP stated that generally he evaluates and treats residents with wounds weekly. The WP stated that he could not remember the exact reasons that some of his evaluations were not weekly; however, he recalled one time his car broke down. The physician stated that it was the facility's responsibility to ensure that weekly wound measurements were done. The wound physician confirmed that he had debrided the sacral wound several times due to necrotic tissue and that the wound was a full thickness wound whose origin was MASD, adding that he last evaluated and debrided the wound on 3/28/22. When asked about the current status of the wound as MASD versus pressure ulcer in accordance with definitions in the MDS 3.0 Manual, he acknowledged It was probably an oversight on my part, adding that he generally does not vary terminology from the origin of the wound. When asked about wound care, the physician stated the wound required cleansing with normal saline or wound cleanser and that the calcium alginate dressing needs to contact the wound base to be effective. The physician confirmed that incorrect wound treatments could impede healing of the sacral wound. An additional observation and interview of R#48's wounds was conducted at bedside on 3/31/22 at 10:05 a.m. The DON was present with the WCN for the wound treatment at the request of the surveyor. The WCN removed the resident's brief and there was a composite dressing on the right/buttock and a Duoderm dressing on the left ischium. The DON inquired about the two separate dressings and the WCN stated that the Duoderm on the left ischium was scheduled for changing every three days. When the WCN removed the dressing from the right buttock wound at 10:09 a.m., the DON acknowledged that she could see the depth of the wound. The DON instructed the WCN to clean the wound and measure the length, width and depth of the wound and check for undermining. During the observation, the WCN measured the wound as 5.0 x 5.0 cm. During this observation, the DON had to instruct the WCN on the correct way to measure the depth with at sterile cotton applicator and to measure the deepest portion of the wound; the WCN did not perform this correctly during the observation and had to make several attempts with oversight by the DON to perform the task correctly. In addition, the DON had to instruct he WCN to measure and correctly identify the area(s) of undermining in the wound. During an interview on 3/31/22 at 10:34 a.m., the DON acknowledged that the sacral wound looked different from the WP report documented on 3/28/22, and stated she doubted the WP's documentation was accurate. The DON confirmed that the resident's sacral wound had deteriorated. The DON also confirmed that the current treatment order directed cleansing the wound with NS in accordance with wound treatment guidelines and she was not aware the facility did not have the normal saline in the facility until staff informed her on 3/29/22 after surveyor intervention. The DON stated the WCN would update the wound documentation and she would contact the WP and obtain treatment orders based on the discovery of the condition of the sacral wound during the observation. Review of R#48's Weekly Wound Report located in the Assessments tab in the EMR dated 3/31/22 at 11:56 a.m., revealed the WCN documented the right buttock wound was acquired on 1/7/22 and had MASD that was unchanged with slough present and 1 cm of undermining, serous fluid with an odor present that measured 5.5 cm x 5.0 cm x 2.5 cm depth. Per the report, infection was suspected, the resident had pain associated with the wound and the treatment was changed to Dakin's solution (antiseptic that kills most forms of bacteria and viruses) wet to dry dressing daily for 30 days and Flagyl (antibiotic) 500 milligrams (mg) tabs crushed daily to wound bed, for 10 days. No location of the undermining was documented. During a concurrent record review and interview on 3/31/22 at 3:49 p.m. with the DON, the DON stated that she had not viewed the 3/31/22 11:56 a.m. Weekly Wound Report documented by the WCN. The DON stated that the WCN was responsible to ensure weekly documentation of both the sacral and left ischial wound. Upon review of the current documentation in the EMR, the DON confirmed the sacral wound that started as MASD had now progressed to a full thickness loss of skin and was a pressure ulcer. The DON also reviewed the 1/7/22 Nursing Skin Assessment and stated that all admitting nurses were required to perform a full skin assessment and document a full evaluation of any existing skin issues. The DON confirmed that this was not done for R#48 upon re-admission on [DATE]. At the direction of the DON, the WCN joined the interview and stated that she documented the wound as MASD because she did not think she could change the WP's assessment. The DON then instructed the WCN to correct her documentation and acknowledged to the surveyor that the wound documentation was inaccurate, based on the current observation of a Stage III worsening pressure ulcer with slough and odor present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that supervision to prevent accidents and/or an environment free of hazards was provided for five residents (R) (R#8, R#10, R#21, R#30, and R#48) of nine sampled residents reviewed for accidents. This failure caused actual harm, when R#8 sustained a fracture while being transported in her Broda chair. In addition, fall interventions such as non-skid strips designed to prevent accidents were not in place. Staff failed to provide the sufficient amount of supervision/assistance during a transfer. Hazardous substances were left within access of a confused resident. Findings included: 1. Review of a policy provided by the facility titled Hazardous Areas, Devices and Equipment dated July 2017, revealed All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness.Examples of environmental hazards include but are not limited to.Equipment and devices that are left unattended or are malfunctioning.Devices and equipment that are improperly used. Review of a document provided by the facility titled Job Description for Activity Aides (AA) dated as reviewed with AA2, 8/23/19 indicated Report all unsafe/hazardous condition equipment immediately. Observation of R#8 on 3/29/22 at 3:28 p.m. revealed the resident was in bed in her room. The resident was unable to be interviewed, due to her cognitive status. During this observation, a Broda chair (reclining, movable chair) with leg rests attached to the chair was noted in the resident's room. Review of R#8's undated admission Record in the Electronic Medical Record (EMR) revealed R#8 was admitted to the facility on [DATE]. The resident had diagnoses including Alzheimer's disease with late onset, unspecified protein-calorie malnutrition, and a contracture of the right ankle. Review of R#8's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/21 revealed staff could not complete a Brief Interview for Mental Status (BIMS) score to determine cognition, and R#8 had short- and long-term memory problems. The assessment indicated R#8 the resident required extensive assistance with bed mobility with one staff member and was totally dependent on two staff for transfers. The assessment indicated R#8 was dependent on staff for locomotion. Review of R#8's EMR care plan, located under the Care Plan tab and dated 5/8/21, revealed R#8 required total assistance from staff with all activities of daily living related to her diagnoses of Alzheimer's disease with dementia, depression, psychosis, and schizophrenia. Per the care plan, the resident required a Broda chair for positioning, initiated 10/27/20. Review of the health status Progress Notes located under the Prog [Progress] Note tab and dated 4/29/21, revealed R#8 sustained an accident three days earlier on 4/26/21. Specifically, the progress note stated Charge nurse reported to Risk Manager, on 4/29/2021 at 0700, that resident presents with discoloration, to left lower extremity. Vital signs initiated and within normal limits. Resident resting peacefully in bed, no physical signs or symptoms of pain observed. Skin assessment performed: edema, heat, and discoloration to left lower extremity, noted. Resident's lateral, left, foot and ankle has [sic] blue/purple discoloration present, with pitting edema. Lateral, posterior portion of resident's calf and patella, has blue/purple discoloration, heat, and mild edema present. Resident is able to [sic] wiggle toes and move foot, without physical signs of pain. Passive ROM [range of motion] performed, with no difficulty or crepitus noted, but resident presents with facial grimacing and moaning, upon palpation of left lower extremity.NP [Nurse Practitioner], notified, and provided orders for stat x-ray. RP [Responsible Party] .notified. RP reports that when resident was rolled away, from visit, on 4/26/2021, her left foot, was noted to be dragging under her Broda Chair. RP reports that staff immediately corrected resident's positioning, and that her foot was under the chair, for less that [sic] 20 seconds. Activities Aide confirmed that she corrected resident's positioning. Resident was provided with PRN [as needed] Tylenol 650 mg [milligrams], PO [per mouth]. X-ray resulted and revealed fracture of left proximal lateral tibia, with 11 mm [millimeters] displacement. NP notified and ordered resident to be sent to ER [emergency room], for further evaluation and treatment. RP notified of X-ray results and order to send resident to ER. RP verbalized understanding and stated that 'accidents happen'. Review of a document provided by the facility titled Skin Condition, dated 4/29/21, reiterated the same information as the health status progress note. Review of the hospital x-ray results dated 4/29/21 indicated R#8 sustained a minimally displaced fracture of the lateral proximal tibia with a subtle medial tibial plateau compression fracture. R#8 also sustained a nondisplaced proximal fibular head/neck fracture. R#8 required no surgery, and the hospital notes indicated the resident had generalized osteopenia. R#8 was readmitted back to the facility from the hospital on 5/3/21. Review of R#8's EMR current care plan, located under Care Plan tab and dated 4/29/21, revealed that, after this accident, a new intervention to recline R#8 in her Broda chair prior to transport. There was no mention in the current care plan to ensure the leg rests were on the Broda chair prior to transport. Review of a document provided by the facility titled Teachable Moment dated 4/29/21 indicated the Activity Director (AD) met with AA2 and wrote When transporting residents to and from visits check resident legs and arms to make sure up and inside w/c [wheelchair] before pushing them to and from the room. This document was signed by the AD and AA2. A review of a document provided by the facility titled Physical Therapy Plan of Care, dated 5/4/21 indicated R#8 sustained a left tibial plateau fracture due to the resident's left foot being caught under a Broda chair. The therapy plan indicated R#8 was unable to hold her legs up while seated in the Broda chair and the resident was dependent on all aspects of care. A telephone interview was conducted on 3/29/22 at 3:24 p.m. with AA2, who confirmed that while she was transporting R#8, the resident's left foot went under the Broda chair. AA2 stated that when this occurred, she lifted the chair and moved the resident's left foot out from under the Broda chair. AA2 stated that R#8's Broda chair did not have leg rests attached at the time of the incident, and that R#8 could lift her legs upon command. During an interview on 3/29/22 at 3:36 p.m., the Director of Rehabilitation stated a pad was placed across both footrests as a response to the 4/29/21 identification of the incident with injury. The Director of Rehabilitation stated this was to prevent R#8's feet from slipping through. The Director of Rehabilitation stated she was not aware R#8's Broda chair did not have leg rests attached at the time of the incident. The Director of Rehabilitation was asked to provide any additional training that therapy may have provided AA2 after the incident. No information was provided by the end of the survey. During an interview on 3/30/22 at 8:25 a.m., the AD stated AA2 alerted her to R#8's left foot being pulled under the Broda chair. The AD stated she would have reported any body part being caught in a piece of equipment and left the resident until nursing could come and assess the resident. During an interview on 3/30/22 at 9:49 a.m., the Risk Manager (RM) stated in the ideal world, AA2 should have notified nursing before moving R#8's foot from under her Broda chair, and the resident should not have been moved until an assessment was completed. The RM stated she did not remember speaking with AA2 and stated never took note of the footrests and if they were on or off the Broda chair. During an interview on 3/30/22 at 12:12 p.m., the Administrator stated it was her understanding that R#8 had her left toe touching the ground/floor and was pushed by AA2. The Administrator stated it was concerning to learn AA2 lifted the Broda chair to release R#8's foot from under the Broda chair. The Administrator stated she would have expected AA2 to have alerted nursing to the incident so nursing could have assessed R#8. 2. Review of the facility's undated policy titled Activities of Daily Living [ADL], Supporting directs Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance. Review of R#48's admission Record located in the Profile tab of EMR revealed R#48 was admitted to the facility on [DATE] for long term care. Review of R#48's quarterly MDS, with an ARD of 1/12/22, documented the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS documented R#48 required the extensive assistance of two people for transfers. Review of R#48's active Care Plan located in the Care Plan tab in the EMR identified R#48 was at risk for falls related to weakness and altered cognition. The care plan also noted the resident had self-care deficits related to overall generalized weakness, required staff assistance with activities of daily living (ADL) functioning, and is at risk for functional declines. Although the 1/12/22 MDS identified that the resident required extensive assistance of two persons for transfers, the care plan called for assist with transfers of one staff with the use of a gait belt. Review of the undated plan of care (POC) [NAME] (Certified Nurse's Aide (CNA) Care Plan) provided by the Director of Nursing (DON) on 3/30/22 at 4:00 p.m. and identified as current, revealed there was no information on staff requirements for transfer. During an observation on 3/30/22 at 7:35 a.m., AA1, who is also a Temporary Nurse's Aide (TNA), was at R#48's bedside and had finished washing and dressing the resident. AA1 instructed the resident to sit at the side of the bed and informed her she would help her transfer her to the wheelchair. R#48 rocked her body forward and backward, stood up with bent knees, was shaky and sat back down on the bed and was slightly short of breath and mouth breathing. The resident did this several times and said she was too weak and asked AA1 to get someone to help her with the transfer. AA1 told her to try one more time and the resident told AA1 to turn around and draped her whole body on AA1 and placed her arms around AA1's waist as they both pivoted. As R#48 stood, still slightly shaky, AA1 turned around and hooked R#48's left arm under her armpit. During this transfer, she did not use a gait belt and performed the stand pivot transfer with only one staff. During an interview on 3/30/22 at 7:45 a.m., AA1 did not know the resident's transfer status and was unable to locate R#48's POC/[NAME]. During an interview on 3/31/22 at 11:15 a.m., the DON stated that AA1 should have viewed the [NAME] for R#48 prior to transferring the resident and should have used a gait belt to perform a safe transfer. The DON was asked about the MDS assessment which stated the resident need the extensive assistance of two staff for transfer. The DON acknowledged in order to perform a safe transfer, the information from the MDS assessment should be followed, and she did not know why the recommendations were not on the care plan or [NAME]. The DON summoned MDS2 to join the interview. During an interview on 3/31/22 at 11:20 a.m., MDS2, confirmed that she was responsible for maintaining the accuracy of R#48's care plan, and it should have been updated for a two-person transfer after the resident was re-admitted from the hospital on 1/7/22. 3. Review of R#30's undated admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated he was originally admitted on [DATE] with type 2 diabetes mellitus with diabetic neuropathy. Review of R#30's quarterly MDS, with an ARD of 1/29/22, revealed the resident had a BIMS of 14, indicating the resident was cognitively intact. Per this MDS, the resident required extensive of one person assistance for toileting. Review of R#30's Care Plan, revised on 3/17/22 and located in the EMR under the Care Plan tab, revealed he was at risk for falls related to morbid obesity and daily psychotropic medications. Per the care plan, the resident had a history of falls, including on 7/13/18, 7/25/19, and 2/2/22. Care plan approaches to prevent accidents included non-skid strips on the floor at bedside, which were to be installed and maintained as of 3/20/15. Observation on 3/28/22 at 2:58 p.m. revealed R#30 did not have non-skid strips next to his bed as indicated on his care plan. Interview on 3/29/22 at 2:40 p.m. with R#30 confirmed he had non-skid strips in his restroom, but not next to his bed. Observation on 3/29/22 at 3:24 p.m. with the MDS Coordinator (MDSC) confirmed that non-skid strips were not in place as indicated on the care plan. In addition, during this observation, a puddle of fluid was noted on the resident's floor under the bedside table by the survey team and confirmed by the MDSC. The MDSC stated that although there were two non-skid strips in front of R#30's commode, there were none next to his bed, and she would notify the maintenance director for installation. During this interview, the MDSC stated that no one had noticed, prior to surveyor intervention, that the non-skid strips were not in place. Review of the facility's policy titled Falls and Fall Risk, Managing, revised March 2018 included Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. Review of the facility's policy titled Fall Risk Assessment revised March 2018 included Policy Statement: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of the facility's policy titled Safety and Supervision of Residents revised July 2017 included .Individualized, Resident-Centered Approach to Safety .4d Ensuring that interventions are implemented .5b Evaluating the effectiveness of interventions; 5c Modifying or replacing interventions as needed. 4. Review of R#10's Face Sheet located in the EMR under the Clinical tab, indicated R#10 was admitted on [DATE] with diagnoses including congestive heart failure (CHF), chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). Review of R#10's progress notes, located in the EMR under the Progress Note tab, revealed R#10 had a history of falls, including falls on 12/7/21, 12/9/21, 1/12/22 and 1/15/22. Review of R#10's quarterly MDS, with an ARD of 12/10/21, revealed the facility assessed R#10 to have a BIMS score of 12, indicating R#10 had moderately impaired cognition. R#10's functional status included the need for limited assistance with bed mobility, extensive assistance with transfers and toileting and supervision with dressing. Review of R#10's Care Plan last revised on 3/19/22 and located in the EMR under the Care Plan tab, revealed a Focus area stating that R#10 is at risk for falls due to COPD, CHF, stage III chronic kidney disease, generalized weakness, cellulitis, lower extremity edema [swelling] .Goal: [R#10's] falls will be minimized thru management of risk factors thru next review. The Interventions/Tasks listed in the care plan included 10/14/20 Non-skid strips to be placed in bathroom due to safety .5/12/21 Strips at bedside and in front of commode due to: Room change. Observation on 3/30/22 at 10:25 a.m. in R#10's bathroom revealed there were no non-skid strips placed on the floor. During an interview on 3/30/22 at 10:20 a.m. with R#10, he stated he has fallen several times. R#10 stated that the non-skid strips that are on the floor beside his bed keep his feet from slipping when he is getting in and out of bed. R#10 was unsure whether there were non-skid strips on the floor in his bathroom. Interview with the DON on 3/31/22 at 2:35 p.m. revealed that the resident had changed rooms, indicating that the non-skid strips had not followed him to his new bathroom. 5. Review of a policy provided by the facility titled Hazardous Areas, Devices and Equipment dated July 2017, revealed, Identification of Hazards. Access to toxic chemicals. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. Review of R#21's undated admission Record in the EMR revealed R#21 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbances. Review of R#21's quarterly MDS with an ARD of 1/19/22 revealed R#21 had a BIMS score of 8, which revealed the resident was moderately cognitively impaired. Review of R#21's current care plan located under Care Plan tab revealed the resident was at risk for alteration in cognition related to dementia. The care plan indicated R#21's cognition varies throughout the day and seemed clearer in the morning. During an observation on 3/28/22 at 12:19 p.m., R#21 was observed to have a bottle of nail polish remover on the windowsill above her wall heater/cooler. During an additional observation on 3/30/22 at 9:01 a.m., upon entry to R#21's room, the nail polish remover was still placed on the windowsill above her wall heater/cooler. The temperature for the heater was set at 75 degrees Fahrenheit (F). The Social Services Director (SSD) was present and grabbed the bottle of nail polish remover, stating R#21 was not to have this in her room. Observation of the bottle of nail polish remover revealed it was labeled, Warning: Extremely Flammable Keep Away From Flame and Storage: Do Not Store Near Fire, Flame or Heat.