**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy titled, Hospice Services, release date [DATE], revealed The hospice, nursing home, and resident/representative collaborates in the development of a coordinated care plan which includes, but is not limited to, the following .Interventions that address, as appropriate, the identification of timely, pertinent non-pharmacological and pharmacological interventions to manage pain and other symptoms of discomfort. Review of R43's admission Record located in the EMR under the Profile tab revealed R43 was admitted on [DATE]. R43 expired on [DATE]. Diagnoses included malignant neoplasm of the brain, altered mental status, pain, anxiety, and other recurrent depressive disorders. Review of R43's admission MDS with an ARD of [DATE] and located in the EMR under the MDS tab, revealed a BIMS assessment was not conducted due to the resident being rarely/ never understood. The resident was identified as having cognitive skills as modified independence. Pain was marked as having occasional pain frequency. Review of R43's Care Plan located in the EMR under the Care Plan tab, initiated on [DATE], revealed R43 had a terminal prognosis. Interventions included administer medications per order .Integrate care with Hospice agency per resident/ resident advocate request. During an interview on [DATE] at 8:35 AM, the Family Member (FM) 1 stated she met with hospice and signed the hospice papers on [DATE]. FM1 stated orders were faxed by hospice to the facility on [DATE]. She stated she was told by a facility nurse that the orders were found on the nursing manager's desk on [DATE] and the order was not documented into the medical record until [DATE]. Review of the Order Summary Report located in the EMR under the Orders tab revealed the following orders prior to hospice services starting: Order date: [DATE] with end date: [DATE]: Lorazepam [anti-anxiety] oral concentrate 2 mg/ml [milligram/ milliliter] Give 1 mg by mouth every 4 hours as needed for severe anxiety for 14 days. Order date: [DATE]: Morphine [pain medication] Sulfate Solution 20mg/ml. Give 0.25ml by mouth every 2 hours as needed for moderate generalized pain/ dyspnea. Morphine Sulfate Solution. Give 0.5ml by mouth every 2 hours as needed for generalized pain/ dyspnea. Review of the hospice Visit Note located in the EMR under the Documents tab, dated [DATE], revealed Start of Care. The narrative revealed entering his first benefit period for terminal diagnosis of glioblastoma [brain tumor]. Review of the hospice Visit Note located in the EMR under the Documents tab, dated [DATE], revealed Is current pain management effective? Yes. The narrative revealed appears pt [patient] has declined since yesterday admit .whispered yes to being in pain. Requested facility administer PRN [as needed] morphine .New order to discontinue acetaminophen, Dulcolax, and Flomax capsules, and schedule 0.25mls of morphine Q4 [every 4] hours per hospice MD [physician]. Review of the Order Summary Report located in the EMR under the Orders tab, dated [DATE], revealed the following: Order date: [DATE]: Morphine Sulfate Solution 20mg/ml. Give 0.25ml by mouth every 4 hours for pain. Morphine Sulfate Solution. Give 0.5ml by mouth every 1 hour as needed for moderate to severe pain or dyspnea. This order was not added until two days after the hospice visit on [DATE]. Review of the hospice fax, provided by the facility and dated [DATE], revealed Discontinue current orders for lorazepam. Start lorazepam 2mg/dl oral concentrate, give 1mg (0.5ml) .every 1 hour as needed for anxiety or restlessness Further review of the EMR Order Summary Report revealed the following: Order date: [DATE]: Lorazepam oral concentrate 1 mg/0.5ml. Give 0.5ml by mouth every 1 hour as needed for Anxiety and Restlessness. These changes in medications were not started until [DATE]. The fax was documented as received [DATE]. During an interview on [DATE] at 10:30 AM, Licensed Practical Nurse (LPN) 2 stated she came in that Friday/Saturday, talked with FM1, and hospice had come in that day. LPN2 stated she found the hospice orders on the manager's desk and confirmed the fax was dated [DATE]. During an interview on [DATE] at 1:06 PM, the Resident Care Manager (RCM) stated the resident was started on hospice care on [DATE]. He stated the changes in medication orders should have been put into place immediately. During an interview on [DATE] at 1:46 PM, the Director of Nursing (DON) stated the resident received hospice visits starting on [DATE] but that the medication changes were not added until [DATE]. She confirmed that although the resident was receiving pain management the hospice orders should have been put in immediately. Based on interview, observation, record review, and policy review, the facility failed to ensure two out of 20 sampled residents (Residents (R)30 and R43) were provided with adequate and or timely nursing care and services after: 1. R30 experienced a fall in which she sustained a significant laceration to her forehead and 2. R43's hospice orders were not implemented in a timely manner. The failure to send R30 to the emergency department (ED) timely resulted in harm when R30's laceration could not be sutured and then required debridement and continued treatment three weeks after the fall. Findings include: Review of the facility's Neurological Evaluation policy dated [DATE] revealed, Neurologic vital signs supplement the routine measurement of temperature, pulse rate, and respirations when a resident is suspected to have hit their head (e.g., a fall), has hit their head or has a traumatic brain and/or spinal cord injury . 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R30 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and muscle weakness. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] in the EMR under the Profile tab revealed R30 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review of this MDS revealed R30 was impaired in range of motion (ROM) to both sides of her upper and lower extremities, dependent on staff for toilet and tub transfers, and required substantial assistance for chair/bed to chair transfers. R30 experienced one fall with injury since the prior MDS assessment. R30 received hospice services. Review of the Care plan dated [DATE] in the EMR under the Care Plan tab revealed R30, had an actual fall with injury r/t [related to] impulsivity, confusion. Intervention in pertinent part included, Neuro-checks per policy and procedure. Review of a late entry Health Status Note, dated [DATE] at 10:40 PM, revealed Resident had a witnessed injury fall in the common area at 1900 [7:00 PM] hrs [hours]. Resident was observed to have leaned forward from her wheelchair and face planted onto the floor in a prone position. Resident had an abrasion to her forehead measuring 3 cm [centimeters] x [by] 1cm. Resident was asked how she ended to the floor and stated she was attempting to get up. Resident's granddaughter and emergency contact #1 [name] was notified, and so was the hospice nurse [name] and nurse manager on duty [name]. Hospice nurse [name] stated that resident should not be sent out to the hospital and that her nurse will be in tomorrow to f.u [follow up] with her. Resident's neuros are wnl [within normal limits] with no latent injuries noted. Resident assessed and was alert to her baseline, name, and place. First aid rendered to the abrasion site, resident transferred to her w.c. [wheelchair]. Resident continues to be on neuros. Resident c.o [complains of] pain and to her forehead and bilat [bilateral] knees and was administered prn [as needed] Tylenol 650 mg [milligrams] with therapeutic effect. Review of the Neurological Record from [DATE] through [DATE], provided by the facility, revealed neuro checks were due on [DATE] at 10:00 PM, 11:00 PM, and on [DATE] at 12:00 AM and 4:00 AM. Sleeping was documented on the form for each of these times; neuros were not completed after 9:00 PM on [DATE] until 8:00 AM on [DATE]. The neuro checks completed at 8:00 AM on [DATE] were within normal limits. Review of the Hospice Notes, revealed no note written on [DATE] of a hospice nurse visit to R30. Review of the ED [Emergency Department] Provider Note dated [DATE] at 6:11 PM revealed, Pt [patient] feet caught in WC [wheelchair] last evening and fell forward on hard linoleum. Was not sent for eval from [name of facility] where witnessed event took place. Pressure dressing applied last evening . Pt reports mild forehead pain . Family notified last night after hospice and hospice nurse stated pt did not need to be sent. Granddaughter brought pt in and is POA [power of attorney] at bedside .Patient has a significant wound on her forehead as well as abrasions to her knees . Large skin tear and maceration on the forehead . The wound is too old to do any type of suture closure but we will irrigate the wound and dress as best as we can . Given the fact that the wound was not adequately treated for about 24 hours, we can discharge on Keflex [antibiotic] as a prophylactic . Review of the EMR Medication Administration Record (MAR), dated [DATE] revealed the Keflex antibiotic was not documented as administered. Review of the Order Summary, dated [DATE] through [DATE] and under the Orders tab in the EMR, revealed wound care to the forehead laceration one time a day every 3 days for cleanse wound, apply bacitracin [antibiotic ointment] and border foam dressing. Review of the Order Summary dated [DATE] in the EMR under the Orders tab revealed R30 received the following treatment to her forehead, initiated on [DATE], Bactine Max External Liquid 4-0.13 % (pain reliever), apply to affected area topically as needed for forehead wound cleansing prior to dressing changes, wound care to include wound washed/cleansed with Bactine Max. Place Adaptec [non-adherent dressing] in wound bed, calcium alginate [dressing used to manage moderate to heavy exudate fluid leaking out of blood vessels into nearby wounds, providing a moist healing environment, and supporting debridement (removal of dead, damaged or infected tissue to improve wound healing)] and then bordered foam to cover site, one time a day every 7 day(s) for wound to forehead. During an observation on [DATE] at 3:08 PM, R30 was observed in a recliner chair in her room sleeping. R30 had a large bandage covering most of her forehead. During an interview on [DATE] at 9:10 AM, Family Member (FM)3 stated R30 experienced a fall on [DATE] and the nurse had R30 up in a wheelchair ready to go to the hospital when she arrived in the facility that evening ([DATE] after the fall). FM3 stated the on-call hospice nurse made the decision not to transport R30 to the hospital. FM3 stated R30 had a pretty good gash on the head. FM3 stated she wanted R30 to go to the hospital and offered to take her, but was told a hospice nurse would come the next morning to assess the wound. FM3 stated the next morning she called the nurse on duty and was told the dressing was wet and the hospice would be coming to look at the wound. FM3 stated she arrived at the facility after 2:00 PM and the hospice nurse had not been into the facility. FM3 stated at 4:00 PM, the nurse on the evening shift took R30's dressing off and she saw the wound. FM3 stated it was a bad wound (laceration with some of the tissue separated and missing) and asked the nurse what she was going to do. The facility nurse then called hospice, reported no hospice nurse had been in to assess the wound, and hospice gave the order to send R30 to the ED. During an interview on [DATE] at 10:42 AM, the Director of Nursing (DON) stated the facility called to have R30 sent to the hospital on [DATE], but hospice declined to send her. The DON stated the nurse on duty at the time of the fall thought the wound was bad enough that it warranted R30 going to the ED. The DON stated if the hospice nurse did not come in on [DATE], the facility nurse on duty should have followed up. The DON stated neuro checks should be completed when residents were known to hit their head and they were important to detect a head injury. The DON stated sleeping was an inappropriate reason not to complete the neuro checks on [DATE] and education had been provided to the nursing staff after this incident. The DON stated by not completing the neuro checks, the facility had missed the opportunity to evaluate R30's status to detect a significant change in mental status. During an interview on [DATE] at 11:18 AM, R30's Hospice Nurse stated she was off duty on [DATE] when R30's fall occurred so the call went to the on-call hospice nurse. The Hospice Nurse stated a resident could go to the hospital with an acute injury. The Hospice Nurse stated she did not know if a hospice nurse assessed R30's wound on [DATE]. During an interview on [DATE] at 12:34 PM, the Resident Care Manager (RCM), Licensed Practical Nurse (LPN) stated he did not see R30's wound until [DATE]. The RCM stated there was a large, deep split with abraded skin on either side. The RCM stated when he saw the wound on [DATE] it was a laceration and not an abrasion. The RCM stated he consulted with R30's medical provider and stated R30 should have gone to the ED on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of the State Agency's Long-Term Care Reporting Portal, review of I&A reports, and staff interview, it was determined the facility failed to ensure residents were free from abuse. This was true for 2 of 4 residents (#23 and #39) reviewed for abuse. This failure resulted Resident #39 and Resident #23 not being free from verbal abuse. Findings include: The facility's Abuse policy, revised 7/23/19, documented the facility prohibited abuse and implemented policies and procedures to prevent all types of abuse, including and not limited to verbal, sexual, physical, and mental abuse. The prohibitions on abuse applied to facility staff, other residents, consultants, volunteers, agency staff, family members, legal guardians, friends, and visitors. The facility's Detecting Abuse policy, revised 7/23/19, documented when identifying events and occurrences that may constitute or contribute to abuse, the facility's procedure was to evaluate the resident for signs and symptoms of the negative psychosocial impact of the event, including but not limited to: - Fear of a person or place, being left alone, being in the dark, disturbed sleep, nightmares. - Extreme changes in behavior (aggressive or disruptive behavior toward a specific person). - Running away, withdrawal, isolating self, feeling of guilt and shame, depression, crying, talking of suicide or attempts. The policy further stated the procedures to protect residents during and after an investigation included increased supervision of the alleged victim and other residents as indicated. These policies were not followed. 1. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including extrapyramidal and movement disorder (a group of neurological conditions that cause either increased movements or reduced or slow movements). Resident #39's admission MDS, dated [DATE], documented Resident #39 was cognitively intact, required one staff supervision for transfer, locomotion, and toileting, and she was occasionally incontinent of bladder and bowel. An I&A report, dated 12/16/21, documented Resident #39 was subjected to verbal abuse from a facility staff member resulting in psychosocial harm, as follows: An I&A report, dated 12/16/21 during the evening shift, documented Resident #39 reported the night nurse [LPN #6] told her she had to stay in bed. The report documented Resident #39 had difficulty sleeping and got up frequently during the night to use the restroom. The report documented Resident #39 reported there is one nurse on night shift that is ultra-mean to me and she tells me that I have to stay in bed because I get up too much. I know they think I am disgusting but I can't help it. The report further documented Resident #39 was in tears when she told the charge nurse she could no longer get out of her chair or walk in her room. She reported it made her feel bad when LPN #6 gets after her and the nurse changes her tone of voice and loses her temper with her. Resident #39 stated she had gone [urinated or stooled] in her brief instead of asking for help to go to the restroom, so she did not have to bother LPN #6. The facility's investigation report, dated 12/21/21, documented the LMSW interviewed CNA #2 and CNA #3 on 12/20/21 about the exchange between LPN #6 and Resident #39 that occurred on 12/15/21. CNA #3 stated she did not witness anything directly, but she overheard LPN #6 relaying what had occurred to CNA #2. CNA #3 stated she did not hear what transpired completely but remembered LPN #6 saying she told Resident #39 she was the boss and Resident #39 needed to wait 30 minutes. CNA #2 stated she did not observe the altercation, but LPN #6 reported it to her. CNA #2 stated LPN #6 told her she informed Resident #39 she needed to wait because she had been to the bathroom [ROOM NUMBER] minutes prior. LPN #6 told CNA #2 she then helped Resident #39 to the restroom and while Resident #39 was on the toilet, she leaned into Resident #39's face and said, I am the nurse and I am the boss and you will do what I say. The investigation documented CNA #2 said [LPN #6] thought it was funny when she was relaying this information to her. The facility's investigation report did not include documentation LPN #6's verbal interaction with Resident #39 was determined as abuse or that LPN #6 received education on abuse and neglect. The investigation did not include documentation CNA #2 and CNA #3 were trained on reporting alleged abuse. Additionally, Resident #39's record did not include documentation she was evaluated for signs and symptoms of potential negative psychosocial impact of the verbal abuse by LPN #6, per facility policy. On 7/12/23 at 11:00 AM, the CEO reviewed Resident #39's I&A and State Agency's Long-Term Care Reporting Portal report and stated the allegation of abuse should have been substantiated. 2. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture) and repeated falls. Resident #23's admission MDS, dated [DATE], documented Resident #23 was cognitively intact. An I&A report, dated 4/4/22, documented Resident #23 was subjected to verbal abuse from a facility staff resulting in psychosocial harm, as follows: An I&A report, dated 4/4/22, documented a staff member, a COTA, reported a concern about the verbal exchange between the PTA and Resident #23 on 4/4/22 at 10:30 AM. The staff member stated the PTA spoke to Resident #23 in a demeaning-like way and treated him like a child. The I&A documented that on 4/5/23, Resident #23 continued to ruminate about the verbal exchange with the PTA and talked to the LMSW about it. The report documented Resident #23 stated he did not want to work with the PTA any longer and could not work with someone who did not respect him. Resident #23 stated he felt like he was talked to like a child. The LMSW interviewed the COTA who witnessed the interaction. The COTA stated he felt the interaction between the PTA and Resident #23 may constitute verbal abuse. The COTA gave a statement of events, as follows: He was in the gym working with another resident when the PTA and Resident #23 entered. He stated the PTA turned down the speed on Resident #23's power wheelchair and Resident #23 appeared visibly upset. Resident #23 attempted to verbalize and began swinging his arms around angrily. The COTA stated the PTA told Resident #23 if you want to be treated like an adult, stop acting like a baby and throwing a fit. Resident #23 had saliva running down his mouth from being upset. The COTA reported the PTA tossed a washcloth at Resident #23 and stated, wipe your mouth off. The facility's investigation report did not determine that the PTA actions constituted abuse. The report stated, the PTA may have acted unkindly but not abusively and that this is likely due to a communication barrier. To prevent this from happening again [PTA's name] was asked to no longer provide therapy for [Resident #23]. The investigation did not include documentation interviews were conducted with other staff and residents to determine if the PTA had any incidents of verbal abuse with other residents had occurred during treatment. Additionally, Resident #23's record did not include documentation he was evaluated for signs and symptoms of potential negative psychosocial impact of the verbal abuse by PTA, per facility policy. On 7/12/23 at 11:00 AM, the CEO reviewed Resident #23's I&A and State Agency's Long-Term Care Reporting Portal report and stated the allegation of abuse should have been substantiated. The facility failed to ensure Resident #23 and #9 were free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness. An MDS admission assessment dated , 5/25/23, documented Resident #24 required a 2-person physical assist for transfers. Resident #24's care plan, dated 5/20/23, directed staff to place her personal items and assistive devices within her reach. A nurse's progress note, dated 6/25/23, stated Resident #24 was found on the floor, between her bed and the wall. On 7/10/23 at 3:15 PM, Resident #24 stated she fell because the care staff moved her assistive devices away from her bed and she was not able to reach them. On 7/12/23 at 12:10 PM, The RCM stated Resident #24 fell while trying to get out of bed on the left side. She also stated the care staff had just been in the room [ROOM NUMBER] minutes prior to providing care and forgot to place the assistive devices within her reach. Based on policy review, record review, I&A review, and staff and resident representative interview, it was determined the facility failed to ensure adequate supervision and interventions for residents to prevent falls. This was true for 2 of 7 residents (#24 and #31) reviewed for falls. This resulted in harm to Resident #31 and created risk of injury to Resident #24. Findings include: The facility's Fall Response and Management policy, revised 5/17/21, documented for a fall without injury staff were to implement immediate interventions to prevent a repeat fall, and for a fall with injury, to revise the care plan with interventions and communicate the event and intervention changes to staff. The policy was not followed. 1. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure, weakness, and repeated falls. Resident #31's care plan, initiated 6/13/23, documented she was at risk for falls. The care plan directed staff to keep her adjustable bed in position for safe transfers, lock the bed brakes, and keep her bed at an appropriate height when she was in bed. Resident #31's I&A reports, documented she fell three times from her bed since admission, resulting in harm after the third fall as follows: - On 6/25/23 at 11:00 PM, Resident #31 had an unwitnessed fall and was found sitting on the floor in her room between the bed and the wall in front of her wheelchair. Resident #31 said she was in bed right before she fell. No injury was reported, and immediate interventions included Resident #31 was assessed, lifted, and seated in her wheelchair. There were no interventions documented in her care plan. - On 6/27/23 at 12:00 AM, Resident #31 had an unwitnessed fall and was found on the floor face down in her room between her bed and the wall. Resident #31 said she was lying in bed right before she fell and was trying to pick something up off the floor. No injury was reported, and immediate interventions included Resident #31 was assisted to bed and transferred to the living area for closer observation. There were no interventions documented in her care plan. - On 7/4/23 at 4:45 AM, Resident #31 had an unwitnessed fall and was found on the floor in her room by the bed. Resident #31 said she was lying in bed before she fell and she was trying to get out of bed. She had a large hematoma on her forehead, and she was to sent to the hospital. The Post Fall Review recommendation was to lock her bed control for up/down function at an appropriate height for Resident #31. The investigation of the fall documented her bed was in the highest position at time of the fall. A nurses note, dated 7/4/23 at 6:56 AM, documented Resident #31 had a large goose egg hematoma, purple in color and was the size of a baseball above her right eye. During an interview, on 7/11/23 at 11:00 AM, Resident #31's representative stated Resident #31 had a third fall with injury when a CNA left the bed in its highest position. During an interview, on 7/11/23 at 2:50 PM, LPN #1 stated Resident #31's bed was in the highest position when she fell on 7/4/23 with her bed control lying on the floor. She stated Resident #31 was on floor on right side of her bed. During an interview, on 7/13/23 at 9:34 AM, CNA #1 stated the CNAs reviewed the [NAME] index on the computer where they charted to obtain information regarding resident cares, such as bed height. She stated residents' bed height should be about knee level unless instructed by the [NAME] index for special heights, such as keeping the bed at a low level. CNA #1 stated Resident #31's bed height should be at knee level. CNA #1 stated she was not aware of any bed locked situations.