**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on incident and accident (I&A) review, record review, and staff interview it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 2 residents, (Resident #79) whose records were reviewed for falls. This resulted in actual harm to Resident #79. Findings include: The Centers for Medicare and Medicaid Services (CMS) State Operation Manual (SOM), Appendix PP, revised 8/8/24, defined 'Avoidable Accident' as an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. Resident #79 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness and abnormalities of gait and mobility. Resident #79's care plan, dated 12/4/24, documented he was assessed to be at risk for falls due to impaired mobility and required extensive assistance with chair to bed transfers. The care plan also directed staff to provide one-person extensive assist with bed mobility and direct supervision while toileting. An I&A report, dated 2/21/25, documented Resident #79 had a fall with injury on 2/16/25 at 12:45 PM and a second fall with injury on 2/16/25 at 5:45 PM. A post fall investigation, dated 2/16/25 at 12:45 PM, documented his first unwitnessed fall occurred while transferring from the toilet to his wheelchair. During that fall he obtained a skin tear measuring 0.4 cm x 0.04 cm. The report also documented Resident #79 verbalized having a 1 out of 10 pain level. Section G of the report documented the removal of Resident #79's wheelchair from within reach as an intervention and cleansing the skin tear. On review of Resident #79's care plan dated 12/4/24, no interventions were implemented to prevent further falls. The I&A report, dated on 2/16/25 at 5:45 PM, documented Resident #79 had a second unwitnessed fall with injury while transferring. During that fall he obtained a laceration to the back of his head. The report did not include the measurements of the laceration. A post fall investigation, dated 2/16/25, documented Resident #79's pain level to be a 10 out of 10 with facial grimacing and yelling inconsolably. The investigation documented the Licensed Nurse observed a rapid decline in his vital signs and called 911 to transfer Resident #79 to the hospital for further evaluation and treatment. The post fall investigation did not include documentation of the severity of Resident #79's injuries after his transfer to the hospital. On 3/19/25 at 3:08 PM, the DON stated the facility failed to train staff to update care plans and implement interventions post falls on the weekends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined the facility failed to ensure the physician was notified timely of a residents' low BG levels and of falls that resulted in head injury. This was true for 1 of 8 residents (Resident #10) whose records were reviewed. Resident #10 was harmed when she experienced a cognitive decline after experiencing multiple unwitnessed falls and multiple low BG levels and the physician was not notified and/or not notified timely. This failed practice harmed Resident #10 when the resident experienced a decline in condition and the physician was not notified in order for the physician to make treatment/care decisions. Findings include: The facility's Resident Change of Condition policy and procedure, dated 11/28/17, documented when the staff recognize a significant change in status the nurse should communicate with the physician to meet the residents' needs. The policy documented the facility was to immediately inform the resident, confer with the physician, and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. The policy defined a change of condition to include deteriorating mobility, falls, and behavior changes. Resident #10 was readmitted to the facility on [DATE], with diagnoses which included repeat falls, Parkinson's Disease, muscle weakness, schizophrenia, diabetes, and major depression single episode. A Mental Health Progress Note, dated 10/2/18, documented Resident #10's thought process was intact, and her associations were logical. The note documented she had normal thought content and no hallucinations. The note documented she was oriented to situation, place, and person and her memory was intact. A quarterly MDS assessment, dated 10/18/18, documented Resident #10 was cognitively intact and required supervision while walking in her room or the corridor. The MDS assessment documented Resident #10 required extensive assistance of one staff member with bed mobility, transfers, toileting, and locomotion on and off the unit. The MDS documented Resident #10 experienced one fall without injury since the prior assessment. Resident #10's December 2018 recapitulated Physician's Orders included the following: - Monitor BGs twice daily and notify the physician if BG was less than 60 or greater than 500 mg/dl, ordered 6/14/18. - Novolog (Insulin Aspart) 12 units subcutaneously at lunch and dinner for diabetes, ordered 6/14/18. - Tresiba (Insulin Degludec) 50 units subcutaneously in the morning for diabetes, ordered 7/25/18 and discontinued 12/4/18. - Tresiba (Insulin Degludec) 45 units subcutaneously at bedtime for diabetes, ordered 7/25/18, and discontinued 12/4/18. - Tresiba (Insulin Degludec) 45 units subcutaneously in the morning for diabetes, ordered 12/4/18. - Tresiba (Insulin Degludec) 40 units subcutaneously at bedtime for diabetes, ordered 12/4/18. a. Resident #10's 11/1/18 through 12/13/18 MAR, documented she had 4 BG levels less than 60 mg/dl. A physician order request, dated 11/6/18 at 9:00 PM, documented her BG level was 44 mg/dl and she was very diaphoretic (sweating). The notification documented she was provided glucose gel and her BG level raised to 81 mg/dl. The notification documented she had a low oral intake at dinner and her pre-dinner BG level was 129 mg/dl. Resident #10 was provided her evening doses of Novolog and Tresiba when her BG was 44 mg/dl. The notification documented Resident #10's morning BG levels were normally below 100 mg/dl with an HS snack provided. The request asked the physician review her BG levels and consider reducing her Novolog and Tresiba. The request was documented as faxed to the physician on 11/7/18, time not noted. The physician did not respond to the request. The physician reviewed the low BG level and her insulin was adjusted on 12/4/18 (28 days) after the request. b. Resident #10's clinical record documented she experienced six falls between 11/11/18 and 12/4/18, and the physician was not notified of falls and/ or not notified timely when she had a change in cognition. Examples include: i. Resident #10's clinical record included a Post Fall Investigation report, dated 11/29/18. It documented she experienced a fall on 11/11/18. Resident #10's clinical record did not contain documentation the physician was notified of the fall on 11/11/18. ii. An I&A Report, dated 11/12/18 at 7:40 PM, documented Resident #10 experienced an unwitnessed fall in her room tripping over the legs of her front wheeled walker. The I&A documented she hit her head on the floor. A physician order request, dated 11/12/18 at 11:35 PM, documented Resident #10 had an unwitnessed fall in her room and she stated she fell on her back and hit her head. The notification documented she had no hematoma noted and neurological assessments were started. The request was faxed on 11/12/18, untimed. The physician responded and signed the request on 11/27/18, 15 days later. iii. An I&A Report, dated 11/13/18 at 11:50 PM, documented Resident #10 experienced an unwitnessed fall from bed. She was found kneeling next to her bed and denied hitting her head. The I&A documented she had a 5 cm by 3 cm bruise on the pad of her left hand near her thumb. The I&A documented she was able to remember her full name and date of birth but was unable to remember her location. The I&A documented she was attempting to go to the bathroom and she got dizzy and fell to the floor. A physician order request, dated 11/13/18 at 11:50 PM, documented Resident #10 was found on the floor kneeling by her bed, by an aide . The notification documented Resident #10 denied hitting her head and she had injured her hand. The notification documented neurological assessments were started per protocol. The request was faxed on 11/14/18 at 9:05 AM. The physician responded to the request on 11/27/18, 14 days later. The physician responded with an order for staff to monitor Resident #10 for latent injury for 72 hours after the fall on 11/13/18 iv. Resident #10's clinical record documented she experienced a fall on 11/14/18 in a Progress Note, dated 11/16/18 at 2:55 AM and on a Post Fall Investigation report, dated 11/19/18. Resident #10's clinical record did not contain documentation the physician was notified of the fall on 11/14/18. v. An I&A Report, dated 11/19/18 at 10:20 AM, documented Resident #10 experienced an unwitnessed fall from her chair in her room. She was found lying on her stomach with her head on her arms. The I&A documented Resident #10 was trying to find her apartment and fell out of her chair. A physician order request, dated 11/19/18 at 1:41 PM, documented Resident #10 experienced an unwitnessed fall and was found on the floor lying face down. The request documented Resident #10 had increased confusion, and lethargy, and she was not requesting assistance. The request documented the nursing staff asked the provider see Resident #10 due to her recent falls on 11/13, 11/14, and 11/19. The request did not include a date of when the notification was faxed to the provider. The physician did not respond to the request. A Progress Note, dated 11/20/18 at 5:20 AM, documented Resident #10 was confused and was yelling out 'help me.' The progress note documented she had weakness and needed verbal reminders to use her walker, and her gait was unsteady at this time. The note documented she complained of pain to the back left-side of her head from when she fell. The note documented Resident #10 verbalized she was having trouble saying, what she wanted to say, and she had slow thought processes. Resident #10 complained of head pain on 11/20/18 and neurological assessments were not completed for another 28 hours after she complained of the head pain. The Progress Notes, dated 11/21/18 at 3:00 AM, 10:40 AM, and 9:52 PM, documented Resident #10 was alert to herself with confusion and she was having increased confusion over the past week, and difficulty expressing her words. One of the notes documented she was afraid of her call light and was asking where the small boy was. A Progress Note, dated 11/22/18, documented Resident #10 was alert to herself with confusion. A Progress Note, dated 11/23/18, documented Resident #10 was alert to herself with confusion. The note documented she called out several times and when staff asked her what she needed, she had a hard time saying what she needed. A Progress Note, dated 11/27/18 at 6:59 AM, documented Resident #10 frequently calling out. The note documented she was more confused over the past few weeks resulting in falls. The note documented her mental health provider noticed an overall decline in Resident #10's cognition. The note documented Resident #10 required more time to complete sentences and experienced an increased difficulty completing sentences. A Progress Note, dated 12/3/18, documented Resident #10 was confused and stated she did not want a snack because she was late for her airplane. vi. A Progress Note, dated 12/4/18 at 11:35 PM, documented during Residents #10's HS medication pass she was assisted to the bathroom and had to be lowered to the floor. The note documented she had lower leg weakness and she was assessed following the assisted fall. The note documented Resident #10's vital signs were WNL except for her BG which was 53 mg/dl. A physician order request to the physician, dated 12/4/18 at 9:00 PM, documented Resident #10 experienced an assisted fall when she was in the bathroom. The notification documented her legs were weak and they gave out on her. The request documented the nursing staff assessed her BG level and it was 53 mg/dl. The provider did not respond to the request. A Progress Note, dated 12/5/18, documented Resident #10 was making inconsistent statements to staff and had a cognitive decline over the past two weeks. The note documented Resident #10 was not herself, and experienced periods of restlessness where staff was unable to redirect her and/or she was sleeping more. On 12/14/18 at 10:55 AM, the DNS with the Administrator present, stated when a resident fell the staff was to complete an incident report and initiate neurological assessments if the fall was unwitnessed, and if the resident hit their head or suspected a head injury. The DNS stated when Resident #10 complained of head pain on 11/20/18, and had slow thought processes, the staff should have notified the physician. Resident #10 experienced a decline in her cognitive and physical ability between 10/2/18 and 12/14/18. The facility failed to notify the physician in a manner and time in which he could respond to the change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, and review of incident reports and facility policy, it was determined the facility failed to ensure professional standards of practice related to neurological checks and assessing, evaluating, and monitoring under a forearm splint and wrap were followed for 1 of 13 residents (Resident #33) reviewed for standards of practice. These failures created the potential for harm if changes in Resident #33's neurological status went undetected and untreated after four falls, one of which resulted in a goose-egg size bump to the forehead and if the forearm splint and wrap caused skin breakdown. Findings include: The facility's Neurological Evaluation policy and procedure, dated 11/28/17, documented: *Neurological vital signs supplement the routine measurement of temperature, pulse rate, and respirations when a resident is suspected to have hit his/her head or had hit his/her head. *The physician's order dictates the frequency of neurological evaluations. *The neurological evaluation consists of assessing the resident's level of consciousness, pupils and eye movement, and motor function response. *Neurological evaluations should be assessed every 15 minutes for an hour, then; every 30 minutes for an hour, then; every hour for 2 hours, then every 4 hours until the physician stated it was no longer necessary or in the 72 hours if the resident's condition is stable and showing no signs and symptoms of neurological injury. This policy was not followed. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including mild intellectual disabilities and difficulty walking. a. An Incident Report, dated 8/23/18 at 9:00 AM, documented while walking at a fast pace, Resident #33 fell and hit her forehead and her right wrist was swollen and bruised. Neurological evaluations were initiated and an x-ray was completed which identified a right wrist fracture. A fax to the physician, dated 8/23/18 at 8:20 PM, documented Resident #33 was sent to the ER for medical treatment on 8/23/18 at 7:00 PM. A Nurse's progress note, dated 8/23/18 at 10:43 PM, documented Resident #33 returned from the ER with a splint on her right forearm and she was wearing a sling. The Neurological Assessment Flow Sheet documented Resident #33's neurological status was not consistently evaluated after the fall on 8/23/18. On 8/23/18 neurological evaluations were not completed at 10:15 AM, 10:30 AM, 11:00 AM, 12:00 PM, 1:00 AM, and 5:00 PM. On 8/24/18 neurological evaluations were not completed at 4:00 AM, 8:00 AM, 12:00 PM, and 4:00 PM. There were no neurological evaluations completed on 8/25/18 or 8/26/18. Per the facility's policy Resident #33's neurological status was to be assessed for 72 hours, through 8/26/18 at 9:00 AM. An Incident Report, dated 8/25/18 at 3:50 PM, documented Resident #33 had an unwitnessed fall, while trying to pick up candy off the floor. There were no neurological evaluations initiated or completed. On 9/13/18 6:45 PM, the DNS stated she expected the nurses to follow the neurological evaluation protocol. The DNS reviewed Resident #33's neurological assessment related to the fall on 8/23/18 and stated the documentation was incomplete. The DNS reviewed Resident #33's clinical record related to the fall on 8/25/18 at 3:50 PM and stated the nurses should have initiated and completed a neurological assessment. b. Resident #33 returned from the ER on [DATE] with a diagnosis of a right wrist fracture and had a splint that was secured with a wrap. There were no physician orders indicating if the splint could be removed. The facility's Removable or Preformed Splint policy and procedure, dated 11/28/17, documented: * Splinting is used primarily to immobilize broken bones. * Nursing and therapy personnel may reapply splints for continuous wear situations and should assess the extremity and apply a splint according to a physician's order. * The removable or preformed splint includes assessing the resident's skin under the splint, neurovascular status, manufacturer's instructions, and circulation, movement, and sensation status. * Document in the resident's medical record splint application and evaluation results and notify the physician of complications and implement new orders. * If physician orders do not indicate the splint may be removed to check skin integrity at least daily, call and clarify orders with the physician. * Establish monitoring for the splint to include: Condition of the resident's skin and neurovascular status of the area distal to the splint during splint application, at least each shift. Resident #33's August 2018 and September 2018 TARs did not document assessments or monitoring under the splint. On 9/10/18 at 2:13 PM, Resident #33 was observed with a splint wrapped loosely and secured in a sling. Resident #33 stated she broke her arm. On 9/13/18 at 6:34 PM, the DNS obtained a verbal order to remove the wrap and splint to assess the skin for Resident #33. The DNS and the Clinical Resource Nurse removed the wrap and splint to Resident #33's right forearm. No redness was noted and bruising was resolving. The DNS reapplied the splint, while the Clinical Resource Nurse was holding Resident #33's right arm securely. The DNS then applied an ace wrap to secure the splint in place. Resident #33 denied pain or discomfort. On 9/13/18 at 6:50 PM, the DNS stated the nurses should have clarified the physician's order to assess the skin under the splint from the fall on 8/23/18 and should assessed under the splint daily to assure there was no skin breakdown. The DNS stated the TAR should have had documentation the licensed nurses assessed and monitored to assure Resident #33's wrap was secure and her circulation, movement, and sensation status was checked every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident and family interview, review of facility policies, record review, and review of facility incident reports, it was determined the facility failed to prevent the development and worsening of pressure ulcers. This was true for 2 of 5 residents (#1 and #24) reviewed for pressure ulcers. These failures resulted in harm when Resident #24 developed a blister on her heel that deteriorated and became an unstageable pressure ulcer and when Resident #1 developed a pressure ulcer on her coccyx. Findings include: The facility's policy Prevention and Treatment of Pressure Ulcers, dated 11/28/17, documented the following: * Residents at risk for developing pressure ulcers were identified using the Braden Scale (an assessment tool widely adopted to assess a person's risk for development of a pressure ulcer). * Pressure ulcer and other wound/skin interventions were created in cooperation with the interdisciplinary team and were implemented to identify, avoid, or decrease the risk of pressure ulcers. * Based on the resident's assessment, clinical status, preferences and needs, routine care may include but is not limited to: redistributing pressure (e.g. repositioning, protecting/offloading heels), minimizing contact with moisture, providing appropriate pressure-redistributing surfaces that are non-irritating, and maintaining/improving nutrition and hydration. * New or existing pressure ulcers and non-pressure related wounds were treated according to the principles of wound healing. * The interdisciplinary team and resident/family cooperated to create goals and interventions to improve wound healing and/or prevent further skin breakdown. 1. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including unsteadiness on feet, unspecified dementia with behavioral disturbance, hemiplegia (paralysis) affecting the left nondominant side, cerebral infarction (stroke), and muscle weakness. A Weekly Skin Integrity Review, dated 7/26/18, documented Resident #24's skin was intact. Resident #24's Braden Scale for Predicting Pressure Sore Risk, dated 7/30/18 at 9:00 AM, documented Resident #24 was at moderate risk for pressure ulcers. Resident #24's admission MDS assessment, dated 8/2/18, documented the following: * Moderate cognitive impairment. * Extensive assistance of 2 persons required for bed mobility and dressing. * Extensive assistance of 1 person with transfers and personal hygiene. * A wheelchair was in use. * Risk for developing pressure ulcers. * One unhealed Stage I pressure ulcer. * Pressure reducing device for chair and bed. According to the Hopkins Medicine website, accessed 10/2/18, pressure ulcers are classified by stages as defined by the National Pressure Ulcer Advisory Panel. A Stage I pressure ulcer is intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Resident #24's September 2018 physician orders, dated 8/8/18, included Opti-foam (a type of dressing) to the right heel every day, a wound nurse consult, and Prevalon boots (pressure reducing) to be in place when in bed every shift. A Physician Order Request, dated 8/8/18 at 10:04 AM, documented a request was faxed to Resident #24's physician. The form documented Resident #24 had a 7 cm by 3 cm bruised, non-blanchable blister on the bottom of her right heel. An order was requested for Skin Prep (a protective film or barrier) to be applied to both heels every day, and application of Opti-foam to the right heel each day. The request also included Prevalon boots for Resident #24 and a wound nurse consult. A Nurse Practitioner signed the document on 8/8/18 at 5:52 PM. Resident #24's current care plan documented the following: * A new skin event of Stage II right heel pressure ulcer on 8/8/18. A Stage II pressure ulcer, defined by the Hopkins Medicine website accessed on 10/2/18, is partial thickness loss of the skin presenting as a shallow open ulcer with a red/pink wound bed, without dead tissue, or may present as a blister. * Pressure reduction in place to bed and chair, initiated on 8/8/18. * Follow facility protocol for wound care, initiated on 8/8/18. * Treatment per physician's order, initiated on 8/8/18. * Notify charge nurse of skin impairment, initiated on 8/8/18. * Heel boots on when up in chair, initiated on 8/27/18. * Heel lift when in bed, initiated on 8/27/18. * Refer to wound nurse as needed, initiated on 8/27/18. An Incident Report, dated 8/8/18, documented a 7 cm by 3 cm bruised, non-blanchable blister on Resident #24's right heel was reported by the CNA to the nurse. Skin Prep and an Opti-foam dressing were applied, and a fax was sent to the physician. Resident #24's record included Weekly Pressure Ulcer BWAT Reports. The weekly reports included inconsistent documentation of the Stage II pressure ulcer identified on Resident #24's right heel. The reports also documented how the ulcer worsened from a Stage II to an Unstageable pressure ulcer during a 30 day period from 8/8/18 to 9/7/18. Examples include: - On 8/8/18 at 10:59 AM, the report documented the Stage II pressure ulcer on the right heel measured 7 cm by 3 cm. A foam dressing was in place and the right heel was elevated off the bed. - On 8/16/18 at 11:25 AM, the report documented the Stage II pressure ulcer on the right heel measured 0.5 cm by 0.5 cm. The nurse documented the wound appeared unchanged and daily dressing changes continued. The wound size had changed and decreased by 6.5 cm and 2.5 cm from the previous measurements, 8 days before. - On 8/23/18 at 4:27 PM, the report documented the Stage II pressure ulcer on the right heel measured 0.5 cm by 0.5 cm. The nurse documented the wound was slightly improved, a foam dressing was in place, and Prevalon boots were in place to both feet. However, the measurements were unchanged from the report 7 days earlier on 8/16/18. - On 8/31/18 at 10:19 AM, the report documented the Stage II pressure ulcer on the right heel measured 7 cm by 3 cm. The blister was flat and dark tissue was present and a foam pad was in place. The wound had increased in size by 6.5 cm and 2.5 cm in 8 days. - On 9/6/18 at 1:29 PM, the report documented the Stage II pressure ulcer on the right heel measured 7 cm by 5 cm. The nurse documented the wound appeared the same as the previous week, a dark scab was present, and a foam dressing was in place. However, the wound had increased in length by 2 cm and a scab was present. - On 9/7/18 at 10:39 AM, the report documented a suspected deep tissue injury pressure area on the right heel that measured 4.1 cm by 6.1 cm. Resident #24 experienced pain during wound treatment. A foam dressing was applied and the heels were floated on a pad. A deep tissue injury according to the Hopkins Medicine website, accessed on 10/2/18, was a localized skin or blister area purple or maroon in color due to the damaged underlying soft tissue from pressure or shear. The area may be painful, mushy, or boggy. - On 9/12/18 at 4:44 PM, the report documented an unstageable pressure ulcer on the right heel that measured 5 cm by 5 cm. The nurse documented the wound was smaller in size with eschar (black dead tissue). A foam dressing was in place and Skin Prep was applied to both heels. On 9/10/18 at 2:24 PM, Resident #24's family member said Resident #24 had really dry skin on her feet, the skin was turning black during the past couple of weeks, and she had an infection on her heel. Resident #24's family member said her feet were not that way when she was in the hospital prior to coming to the facility. On 9/10/18 at 2:39 PM, Resident #24's family member said the facility told her there was a sore on Resident #24's heel and did not say why the sore appeared. Resident #24's family member said the sore on her heel was not present in the hospital. On 9/12/18 at 3:40 PM, a large purple/black area was observed on Resident #24's right heel and an Opti-foam dressing was in place. The Wound Nurse (RN #1), said when Resident #24 came to the facility from another facility her skin was intact. RN #1 said Resident #24 was not on an air mattress and the pad was placed after the ulcer developed on her right heel. On 9/12/18 at 3:44 PM, the DNS said there was a deep tissue injury on Resident #24's heel and it developed in the facility. The DNS said Resident #24 was at moderate risk for skin breakdown on admission. The DNS said every 2-hour turning was initiated for Resident #24 upon admission, but there was no place to document it was done. The DNS said the normal standard of care was to initiate measures on the 48-hour care plan, such as a pressure reduction mattress. The DNS said the heel lift pad was initiated on the care plan after the pressure ulcer developed on Resident #24's heel. The DNS said on 8/8/18, Resident #24's pressure sore was noted as a blister that was believed to be caused by the wheelchair. On 9/14/18 at 9:41 AM, RN #1 the wound nurse, stated on Resident #24's Weekly Pressure Ulcer BWAT Reports, dated 8/16/18 and 8/23/18, she meant to document the right heel wound measured 5.0 cm by 5.0 cm, not 0.5 cm by 0.5 cm. Resident #24 developed an avoidable pressure ulcer on her right heel at the facility, and it worsened from a Stage II to unstageable. 2. Resident #1 was readmitted to the facility on [DATE], with multiple diagnoses including a stroke and muscle weakness. Resident #1's care plan, revised 8/8/18, documented she had a history of skin breakdown at the coccyx. The care plan did not address Resident #1's pressure ulcer to the coccyx found on 8/25/18. Resident #1's quarterly MDS assessment, dated 8/9/18, documented Resident #1 was moderately cognitively impaired and required 2 person extensive assistance with bed mobility and transfers. The MDS assessment documented Resident #1 was at risk for pressure ulcers and had no unhealed pressure ulcers. An Incident Report, identified as a late entry on 8/27/18 for an incident on 8/25/18 at 11:30 AM, documented during cares the CNAs found an open area to Resident #1's coccyx. The open area measured 2 cm x 0.5 cm and depth of 0.5 cm with no odor or drainage. The report documented RN #2 cleansed the area and applied an Opti-foam dressing to the open area. Nurse's progress notes from 8/25/18 to 9/3/18, and 9/7/18 to 9/10/18, did not include documentation of the Stage II pressure ulcer to Resident #1's coccyx. Weekly Pressure Ulcer BWAT Reports, from 8/31/18 to 9/12/18, had inconsistent documentation of when the Stage II pressure ulcer to Resident #1's coccyx was identified. Examples include: - On 8/31/18 at 9:59 AM, RN #1 the wound nurse, documented Resident #1 had a Stage II pressure ulcer to her coccyx that measured 3 cm x 1 cm with 0 cm in depth. The report documented the initial observation of the pressure ulcer was dated 8/29/18. The report documented there was a foam dressing on the coccyx area and the dressing was clean, dry, and intact. - On 9/4/18 at 1:30 PM, RN #2 documented Resident #1 had an initial observation of a Stage II pressure ulcer on 9/4/18. The pressure ulcer was on Resident #1's coccyx and measured 3 cm x 3 cm with a depth of 0.1 cm. The pressure ulcer had a scant amount of serosanguineous (yellow in color with small amounts of blood) drainage. - On 9/6/18 at 1:24 PM, RN #1 documented Resident #1 had a Stage II pressure ulcer to her coccyx which was initially observed on 8/8/18. The pressure ulcer measured 3.0 cm x 4.0 cm with a depth of 0 cm. RN #1 documented a foam dressing had a scant amount of serosanguineous drainage when removed from the coccyx. - On 9/12/18 at 5:01 PM, the report documented Resident #1 had a Stage II pressure ulcer to her coccyx which was initially observed on 8/31/18. The pressure ulcer measured 0.3 cm x 0.3 cm with a depth of 0 cm and no drainage. The 4 Weekly Pressure Ulcer BWAT Reports documented 4 different dates of when the Stage II pressure ulcer was initially observed or identified. An Incident Investigation Report, dated 9/4/18, documented on 8/25/18, staff noted 2 open areas to Resident #1's coccyx. The report documented both areas were superficial and small in area. The investigation report documented nursing staff were cleaning and dressing the wound as ordered and Resident #1 had a cushion for her wheelchair, which she spent large amounts of time sitting in. Resident #1's August 2018 and September 2018 weekly skin checks on the TAR were blank. A Nutrition Progress Note, dated 9/11/18 at 10:19 AM, documented Resident #1 had no skin issues. On 9/10/18 at 11:53 AM, Resident #1 was observed sitting in her electric wheelchair. Resident #1 stated she had an open area to her coccyx area. Resident #1's electric wheelchair did not have a cushion. Resident #1 stated she had never had a cushion for her wheelchair. Resident #1 stated she gets up by 9:00 AM and laid back down by 2:00 PM every day. On 9/10/18 at 3:00 PM, Resident #1 was observed in her room laying on her back on an air mattress bed. On 9/11/18 at 9:57 AM, Resident #1 was observed sitting in her electric wheelchair without a cushion. On 9/12/18 at 1:59 PM, RN #1 was observed assessing Resident #1's open area to her coccyx. RN #1 stated to Resident #1 the dressing to her coccyx had fallen off and needed to be replaced. RN #1 stated the wound was healing well and needed a dressing to protect the fragile healing skin for another week. On 9/12/18 at 2:01 PM, LPN #2 was observed applying an adhesive dressing. LPN #2 stated the open area to Resident #1's coccyx area was approximately 1 cm x 1 cm in size. On 9/13/18 at 4:10 PM, the DNS and the Clinical Resource Nurse stated the facility had a delay in treatment for Resident #1's open area to the coccyx that was discovered on 8/25/18. The DNS stated the nurses should have documented daily in the nurses' progress notes, updated the care plan, and transcribed the physician's orders to the TAR for dressing changes and monitoring to Resident #1's wound. The DNS stated if the TAR was left blank that meant the treatment was not done. The DNS was unable to explain why the initial observation dates were different on the Weekly Pressure Ulcer BWAT Reports and the reports were based on the pressure ulcer found on 8/25/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to provide adequate supervision to meet residents' needs. This was true for 1 of 2 residents (Resident #33) reviewed for supervision and accidents. Resident #33 was harmed when she fell and sustained a fractured forearm when staff failed to implement interventions and provide adequate supervision. Findings include: The facility's Fall Response and Management policy, dated 11/28/17, documented if there was no injury staff were to obtain vital signs including postural (orthostatic) vital sign measurement. Document the fall in the resident's medical record and implement immediate interventions to prevent a repeat fall. The policy further stated if there was an unwitnessed fall or resident injury staff were to obtain an x-ray if a fracture was suspected and monitor neurological assessments. Staff were also to complete a post-fall investigation and event report and revise the care plan as appropriate, and document the incident or injury in the resident's medical record. This policy was not followed. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including mild intellectual disability and difficulty in walking. A quarterly MDS assessment, dated 8/13/18, documented Resident #33 had moderate cognitive impairment, required supervision with ambulation, had limited ROM (range of motion) impairment to her lower extremities, and had experienced 2 or more non-injury falls. A Fall Risk Assessment Tool, dated 8/20/18, documented Resident #33 had a history of falls within the last 3 months, impaired functional mobility, and had cognitive impairment. The Fall Risk Assessment scored Resident #33 a 7 out of 10 and was considered a risk for falling. The ADL care plan, dated 5/31/18, documented Resident #33 was independent with ambulation and transfers. Resident #33's care plan documented Resident #33 had a history of falls and had cognitive impairment. The care plan interventions were documented as follows: * Assist to steady/assist resident as needed due to impaired balance with right arm sling in place, dated 9/12/18. * Encourage resident to wear nonskid socks and/or shoes when ambulating, revised 6/1/18. * Fall risk assessment Quarterly and as needed, revised 6/1/18. * INFO: resident ambulates independently, revised 6/1/18. * Have commonly used items within easy reach, dated 5/17/18. * Request therapy evaluation as appropriate, revised 6/1/18. Resident #33's record included 4 incident reports of 5 falls, witnessed and unwitnessed, with 2 injuries in 2 days. Examples include: a. An Incident Report, dated 8/23/18 at 9:00 AM, documented Resident #33 fell while she was walking at a fast pace. The report documented she hit her forehead and her right wrist was swollen and bruised. A physician's order, dated 8/23/18, documented STAT (immediate) x-ray of the right wrist. A Nurse Practitioner progress note, dated 8/23/18 at 12:40 PM, documented Resident #33 had a goose-egg size bump on her forehead and a noticeably swollen and bruised right wrist and they were waiting for x-ray results. A Radiology Report, dated 8/23/18 at 6:07 PM, documented Resident #33 sustained a fractured right wrist. A fax to the physician, dated 8/23/18 at 8:20 PM, documented, .was not able to get a hold of on call provider. X-ray positive for distal radial fracture. Pt [patient] was sent to [name of hospital] ER for medical treatment at 7:00 PM. The ER Report, dated 8/23/18, documented Resident #33 was seen for a wrist fracture from a fall. The discharge instructions from the ER stated to have Resident #33 follow-up with an orthopedic physician and return to the ER if she experienced numbness or tingling of the fingers. A Nurse's progress note, dated 8/23/18 at 10:43 PM, documented Resident #33 returned from the ER with a splint on her right forearm and sling. The nurses' progress notes did not document Resident #33 had a fall, she was assessed by the Nurse Practitioner, x- rays were obtained, and Resident #33 sustained a right wrist fracture and a large bump on her forehead. b. An Incident Report, dated 8/24/18 at 3:00 PM, documented Resident #33 had a witnessed fall in the activity room. She landed on her knees and there was no injury. An Incident Investigation and Conclusion report signed by the DNS on 8/27/18, and signed by the Administrator on 9/5/18, documented Resident #33 had a second fall in 2 days. The report documented the IDT agreed to get an order for an OT evaluation and treatment, which was to be completed on 8/27/18. A physician's order, dated 8/27/18, documented Resident #33 was to receive an OT evaluation and treatment 5 times a week. An OT evaluation and plan of care, dated 8/27/18, documented Resident #33 was referred to OT due to new onset of decreased functional mobility, decreased strength, decreased coordination, decreased postural alignment, falls/fall risk, fracture, functional limitation with ambulation, and increased need for assistance from others. Resident #33's care plan did not include OT. The nurses' progress notes did not include documentation Resident #33 had a fall in the activity room on 8/24/18. c. An Incident Report, dated 8/25/18 at 3:50 PM, documented Resident #33 was found sitting on the floor in the dining room. The 3 witness statements documented Resident #33 was found on the floor and they did not witness her fall. A nurses' progress note, dated 8/25/18 at 4:12 PM, documented a volunteer found Resident #33 sitting on the ground in the dining room. Resident #33 stated she was trying to pick up candy off the ground and fell. Resident #33 stated she did not hit their head. The progress note also documented there were no injuries and Resident #33's vital signs were stable. An Incident Investigation and Conclusion report signed by the DNS on 8/27/18, and signed by the Administrator on 9/5/18, documented since Resident #33 had a third fall in three days, staff were to encourage her to use a wheelchair for the rest of the day, as she was scheduled to be evaluated by OT on Monday, 8/27/18. The report also documented Resident #33 agreed to use the wheelchair for a brief time and she was educated to ask for staff assistance to get items off the floor. Resident #33's clinical record did not include neurological evaluations for the fall on 8/25/18 at 4:12 PM. d. An Incident Report, dated 8/25/18 at 5:20 PM, documented Resident #33 was found on the ground near the entryway of the dining room. No injuries occurred, and Resident #33 was helped into a wheelchair and pushed to the table. Staff were helping with dinner and Resident #33 attempted to get up from the wheelchair and the wheelchair rolled back, Resident #33 fell on her bottom. The report documented no injuries occurred, and Resident #33 did not hit her head. An Incident Investigation and Conclusion report signed by the DNS on 8/27/18, and signed by the Administrator on 9/5/18, documented: * Resident #33's sister stated she would like to have Resident #33 use a walker or a cane due to the high number of recent falls. *A cane or walker would be counter indicated, as Resident #33 could not bear weight on her right wrist. * Staff encouraged Resident #33 to use the wheelchair until she was evaluated by OT. * The IDT felt Resident #33 continued to be appropriate for independent ambulation despite recent falls. * Resident #33 would have a difficult time remembering to stay in a wheelchair due to her cognition. * Resident #33 continued to remain in areas of high visibility most of the time. * Resident #33 was independent with transfers and bed mobility. * An OT evaluation was pending. On 9/10/18 at 2:09 PM, Resident #33 stated she fell and broke her arm. Resident #33 was observed with a splint and wrap to her right forearm. She was ambulating around the facility at a hurried pace. On 9/11/18 at 9:00 AM, Resident #33 was observed greeting visitors when entering the facility. She did not have an assistive device for balance and a splint was in place to her right forearm. On 9/13/18 at 5:16 PM, the DNS stated the facility did not complete fall assessments after each fall and the care plan was not updated for Resident #33. The DNS stated the nurses should have documented the 8/23/18 and the 8/24/18 falls in the nurses' progress notes. The DNS was unable to provide documentation for weight bearing status and treatment for Resident #33's right forearm fracture. The DNS was unable to provide evidence of what changes had been made to Resident #33's care plan after each fall. The DNS was unable to provide evidence of increased supervision for Resident #33. On 9/13/18 at 6:12 PM, the Clinical Resource Nurse stated Resident #33 should have had orders for Physical Therapy to evaluate and treat for balance and gait training. On 9/14/18 at 10:25 AM, the DNS stated Resident #33 did not follow up with an orthopedic surgeon because she did not have surgery. She stated the Medical Director was following Resident #33's care for the right wrist fracture. On 9/14/18 at 10:27 AM, the Medical Director stated he was following Resident #33's care for her right wrist fracture. The Medical Director stated he was ordering a follow-up x-ray to determine if the fracture was healing. The Medical Director stated Resident #33 should have been evaluated and treated by Physical Therapy after the fall on 8/23/18.