**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and treat the cause of new pain in left arm; failed to timely review x-ray results; failed to relay x-ray results to physician; failed to obtain verbal or telephone order from physician for pain patch for one resident (R4) in a total sample of 3 residents (R4, R5, and R6). These deficient practices resulted in harm for R4 experiencing new onset left arm pain for 34 days with limited mobility due to a left humerus fracture diagnosed at an outside hospital. Findings include: On 08/13/24 at 12:48pm V19 Medical Doctor (MD) stated, R4 came to the emergency room (ER) unable to move his (R4) left arm and was found to have a subacute fracture to the left humerus. We (medical staff) think the fracture is a pathologic fracture from the cancer, but the problem is how long did he (R4) have this fracture without it being treated. He (R4) was admitted with acute kidney injury (AKI), fecal impaction, dehydration, subacute fracture and pneumonia. R4's hospital note dated 07/30/24 documents in part that R4 has a diagnosis of metastatic cancer of unknow origin (present on admission), and also noted that R4 had significant left arm pain. R4 was unable to move arm on exam .X-ray of the left humerus showed subacute fracture of the proximal left humerus. R4's diagnosis includes but are not limited to Major depressive disorder, Chronic respiratory failure, Chronic obstructive pulmonary disease, Morbid obesity, Venous insufficiency, Sleep Apnea. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 13 which indicates R4's cognition is intact. On 08/12/24 at 12:01pm V20 Licensed Practical Nurse (LPN) stated, (R4) did complain of pain to his (R4) left arm. (R4) complained of arm pain for about a week or so before (R4) left. At first, (R4) wasn't complaining about the arm then (R4) started complaining of arm pain. (R4) told me (V20) that the lady came to draw (R4's) blood and (R4's) arm had been hurting ever since then. (R4) couldn't lift (R4's) arm anymore, (R4) said the arm hurt to lift. (R4) would use (R4's) right hand to lift (R4's) left arm because the left hurt (R4) too bad to try to move. The DON (Director of Nursing) and the doctor both knew about the pain in (R4's) arm. I'm (V20) not sure if they (DON and Doctor) did anything about the pain, possibly an x-ray. Record review of R4's physicians orders show that an x-ray of R4's left shoulder was ordered on 06/25/24 due to pain. Record review of radiology results of R4's x-ray to left shoulder taken on 06/26/24 show that V2 reviewed R4's left shoulder x-ray results on 07/19/24. Record review of R4's progress notes show that no documentation of x-ray results was communicated to V22 until 07/19/24 by V2. On 08/13/24 at 2:00pm V2 Director of Nursing (DON) stated that R4 was having new pain and R4 denied anything happened to his arm. V2 stated that V2 was auditing the chart on 07/19/24 and noted that there was no documentation about R4's x-ray done on 6/26/24, so V2 notified V22 medical doctor. On 08/13/24 at 1:15pm V13 Certified Nursing Assistant (CNA) affirmed that R4 started complaining of pain to R4's left arm approximately 2 weeks before R4 left the facility. V13 stated that V13 told the nurse that R4 was complaining of pain to R4's left arm. On 08/13/24 at 2:22pm V16 CNA stated that R4 complained of pain to his (R4) left arm starting a few weeks before R4 left the facility. V15 told the nurse that R4 was complaining of pain and the nurse gave R4 Hydrocodone. On 08/14/24 at 10:30am V22 MD stated, I (V22) don't remember ordering lidocaine patch for (R4), the nurses might have just put the order in my (V22) name. I (V22) don't recall anyone informing me (V22) of any x-ray results. In my (V22) practice I (V22) usually don't order Lidocaine. That order I (V22) did not give. I (V22) usually look at what causes the pain instead of just ordering a patch. I (V22) don't have a memory of the DON calling me (V22). The nursing home has their own specific nurse practitioner (NP). I don't have an NP. It's not normal for staff to put an order in my name and I (V22) expect staff to call me (V22). My (V22) name is on (R4's ) chart as the attending, so the nurse probably just picked my (V22) name for the lidocaine order. On 08/14/24 at 10:55am V2 stated, Residents with pain need to be assessed to find out where the pain is and the level of pain and then give them (residents) PRN (as needed) pain medications. New pain is considered a change of condition. Some residents have psychological pain. For new pain an SBAR (situation, background, assessment and recommendation) should be done, the doctor should be notified and the family of the resident if the resident is not alert, and then give the resident whatever the doctor orders. For severe pain we (nurses) should send the resident to the hospital. We (nurses) check for swelling and bruising in the area of pain, and for safety purposes do an x-ray. R4's progress notes dated 06/25/24 through 07/29/24, show no SBAR for new pain, no documentation that physician was notified of new pain, and no documentation of next of kin notification of new pain for R4 found as V2 stated in above interview should be completed for new pain. On 08/14/24 at 1:55pm V23 LPN stated, I (V23) am not familiar with R4. I (V23) don't know how my (V23) name can be on an order for R4 because I (V23) don't ever take care of R4. R4 was in room with others and sometimes when R4 would put the call light on, I (V23) would answer the call light and R4 would ask me (V23) to tell R4's nurse (R4) needs pain medication, water or that (R4's) oxygen wasn't working but that's it. I (V23) don't know how the order was entered under my (V23) name. On 08/14/24 at 2:41pm V1 Administrator stated, Staff are not allowed to share passwords. The nurse should transcribe the order correctly. With any change in condition the nurse is to notify the doctor. The nurse cannot enter an order without contacting the doctor. On 08/14/24 at 2:50pm V24 RN stated, Actually there was a time when R4 came from an appointment, and I (V24) saw a prescription for lidocaine patch to his (R4) left arm. Normally nurses have to advise the doctor or the NP if we (nurses) get an order from a resident's appointment. I (V24) don't know when the pain in R4's arm started. Normally R4 would just ask for the Norco for pain but then one day R4 wanted the Norco and the lidocaine patch. R4 Physician Order Set (POS) dated 07/19/24 documents in part, Lidocaine External Patch 5% .apply to left arm. Facility's undated policy titled Pain - Clinical Protocol documents in part, Assessment and Recognition .1. The physician and staff will identify individuals who have pain or who are at risk for having pain .a. This includes reviewing know diagnoses and conditions that commonly cause pain .2. The nursing staff will assess each individual for pain whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .5. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life. Facility's undated policy titled Change in a Resident's Condition or Status documents in part, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and /or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a .d. significant change in the resident's physical/emotional/mental condition .2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Facility's undated policy titled Activities of Daily Living (ADL's), Supporting documents in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's) .1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADL's) do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADL's are unavoidable .a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADL's. Facility's undated policy titled Resident Rights documents in part, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .c. be free from abuse, neglect, misappropriation of property, and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide ice for a resident's orthopedic cold therapy ice machine used for pain and swelling and failed to timely provide and administer a controlled substance seizure medication to a resident which affected one resident (R1) of four residents (R1, R2, R3, and R4) reviewed for improper nursing care and resident rights. This failure resulted in R1 experiencing a seizure and emergently being sent to the hospital. Findings include: R1's admission Record, documents, in part, that R1's diagnoses include encounter for other orthopedic aftercare, epilepsy, lack of coordination, difficulty in walking and unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, that R1's Brief Interview for Mental Status (BIMS) score is a 13 which indicates that R1 is cognitively intact. R1's Functional Status for Functional Limitation in Range of Motion for upper extremity is coded as 1 which indicates impairment on one side. R1's Order Summary Report documents, in part, orders as followed: Apply cold therapy machine to right arm to reduce swelling as needed (start date 2/3/23) and Apply cold therapy machine to right to reduce swelling and pa (pain) as needed (start date 2/5/23). R1's Care Plan, with admission date 2/3/23, documents, in part, a focus of (R1) has an alteration in musculoskeletal status r/t (related to) right arm fracture with an intervention of heat/cold applications as ordered and as tolerated. On 3/14/23 at 10:18 am, V6 (Nurse Practitioner, NP) stated, V6 is the in-house NP who rounded and visited R1 on multiple occasions during R1's one month stay at the facility. V6 stated, R1 was admitted from the hospital after R1 had surgery to repair a shoulder fracture from a fall in the community. V6 stated, R1 came from the hospital with 2 cold therapy ice machines that were to be filled with ice and water. V6 stated, the cold therapy ice machine was a great help for (R1). V6 stated, Ice machine was lifeline for (R1's) pain. V6 asked if at any time was there was an incident when no ice was in R1's cold therapy ice machine. V6 stated, Yes. I (V6) was making rounds. (There was) no ice in (R1's). (V6) and (V9, Assistant Director of Nursing, ADON) dealt with it. Ice had not been delivered yet that morning. V6 stated, R1 would have pain with ice machine off most of the time. V6 stated, V14 (Wound Care Nurse) informed V6, It's magical when talking about the cold therapy ice machine. In R1's Physician's Progress Notes, V6 (NP) documented, in part, the following notes: 1) On 2/8/23 at 9:30 am: . (R1) c/o (complained of) pain in R (Right) shoulder surgical site, noted ice pump was off last night. Back up pump is at bedside, refilled with water and ice, and re-initiated at bedside with (V6) and (V9, ADON). 2) On 2/20/23 at 12:30 pm: . (R1) also c/o surgical site pain, noted ice pump is not on. (V6) reinforced nursing importance of having ice pump on for pain management. 3) On 3/2/23 at 10:05 am: . Ice machine in not on due to no ice at night sift, ensure ice machine in on, reconnected this morning with good (pain) relief. On 3/15/23 at 12:23 pm, V14 (Wound Care Nurse) stated, V14 was seeing R1 for R1's right shoulder surgical incision care. V14 stated, the cold therapy ice machine had a double lumen tubing that came out of the ice bucket where ice cold water would flow from the ice bucket through one lumen, up the to pad that was secured on R1's right shoulder and then the ice cold water would return back down through the other lumen to the ice bucket. V14 stated on one occasion, V14 did fill up R1's ice bucket due to R1 stating that the cold therapy ice machine was not cold and that V14 had observed mostly water in the ice bucket. On 3/14/23 at 12:24 pm, V9 (ADON) stated, R1 was using the cold therapy ice machine to help with both pain and swelling of R1's surgical site. V9 stated, staff puts ice in the ice bucket which is connected to a wrap that looks like a blood pressure cuff that goes over R1's right shoulder. V9 stated, one morning, V9 did assist R1 with filling ice in the cold therapy ice machine due to staff had not gotten to her yet, and the ice machine bucket was mostly water in the bucket. R1's Medication Administration Record (MAR) for February 2023 documented, in part, that for R1's order to apply cold machine to right arm to reduce swelling and pain as needed, only one administration entry (2/17/23) was noted documented by nursing staff. On 3/14/23 at 12:57 pm, V11 (LPN) stated that R1's cold therapy ice machine had a bucket that had a line at the bottom of the ice box where staff would fill small amount of water and then fill the remaining box full of ice. V11 stated, V11 taught the CNAs about R1's cold therapy ice machine and how to refill the majority of the ice box with ice. V11 stated, R1 wanted it on all the time and used to reduce swelling and to help with pain. On 3/15/23 at 1:43 pm, V2 (Director of Nursing, DON) stated that non-pharmacological interventions for pain include ice (cold therapy). V2 stated, for the nursing staff must go to the kitchen to retrieve ice from the ice machine and brings it back upstairs to the floor. V2 stated, if nursing staff need to get ice during the night shift, the staff member will retrieve a key from the receptionist desk and go downstairs to unlock the kitchen to access the ice machine. V2 stated, V2 did recall a complaint from R1 about not having ice, and when V2 followed up with staff, V2 stated, a CNA was given a hard time about trying to get ice in the kitchen. V2 stated, V2 then got the message out to kitchen staff to allow nursing staff to retrieve ice from the kitchen. V2 stated, R1's cold therapy ice machine was used to help with R1's swelling and pain. R1's Order Summary Report documents, in part, the Clonazepam orders as follows: Clonazepam Oral tablet 1 mg (milligram). Give 3 tablet by mouth two times a day for anticonvulsants (order date of 2/3/23) and Clonazepam tablet 2 mg. Give 1 tablet by mouth two times a day for anticonvulsants. Add with 1 mg = (equal to) 3 mg (order date of 2/5/23). R1's Medication Administration Record (MAR) for February 2023 documents, in part, that for the scheduled Clonazepam tablet 2 mg. Give 1 tablet by mouth two times a day for anticonvulsants. Add with 1 mg = 3 mg on 2/5/23 at 9:00 pm, V15 documented a chart code of 9 which indicates Other/See Progress Notes. In R1's Orders - Administration note (EMAR, electronic MAR note), on 2/5/23 at 9:04 pm, V15 (LPN) authors, Clonazepam tablet 2 mg. Give 1 tablet by mouth two times a day for anticonvulsants. Add with 1 mg = 3 mg. On order MD (Doctor) aware. On 3/15/23 at 12:03 pm, V15 (LPN) stated, on 2/5/23, R1 stated that R1 was allergic to anything blue. V15 stated, when V15 went to administer the Clonazepam 1 mg tablets (blue in color), R1 stated that R1 didn't want to take the blue colored Clonazepam (1 mg dose) due to R1's allergy to the blue dye. V15 stated, I (V15) documented it. To call (R1's) doctor or pharmacy to change the medication (Clonazepam dose). When this surveyor asked if V15 called R1's doctor on 2/5/23, V15 stated, No. I (V15) endorse to the morning nurse (V11, LPN). At night, I (V15) don't want to wake the doctor up. In R1's Orders - Administration noted, on 2/5/23 at 9:41 pm, V15 (LPN) authored, Clonazepam oral tablet 1 mg. Give 3 tablet by mouth two times a day for anticonvulsants. The medication comes in a blue color, and (R1) 'state I (R1) can't take anything with blue dye.' MD aware. On 3/15/23 at 3:59 pm, when this surveyor asked V11 (LPN) about V11's authored EMAR note (2/6/23 at 11:45 am) which documented, in part, Physician needs to change order, V11 stated, on 2/6/23, V11 punched out one of R1's Clonazepam 1 mg tablets from the controlled substance medication dispensing card and showed the blue table to R1. V11 stated, R1 was allergic to the blue dye in the medication. V11 stated, V11 then called the pharmacist and was informed that the 2 mg tablets were white in color; therefore, R1 would be able to take one 2 mg tablet and a half of another 2 mg table of Clonazepam to equal the ordered 3 mg dose. V11 stated, V11 then phoned V18 (Nurse Practitioner) on 2/6/23 for the new order of Clonazepam 2 mg tablets to get the 3 mg dose. V11 stated, At first, I (V11) thought I (V11) didn't need a new order for the different color. I (V11) called for a stat order. This surveyor then asked V11 if V11 had R1's new Clonazepam 2 mg tablets order (total dose of 3 mg) prescription signed by V18, and V11 stated, For the change in color (of Clonazepam), it ended up that I (V11) needed a new script. I (V11) got it signed right then and there. I (V11) put the new order in and asked for it stat. (V6, NP) was here. I (V11) said (to V6), 'Can you please write the script?' V11 stated that R1's Clonazepam 2 mg tablets (white in color) were delivered to the facility on the same day when V11 changed the Clonazepam order which was the same day that R1 was sent to the hospital after having a seizure. This surveyor reviewed with V11 from R1's electronic medical record (EMR) where R1 was sent to the hospital after a seizure in the facility on 2/7/23, but that V11 had documented in a Nurses Note on 2/6/23 at 5:23 pm, D/C (discontinue) Clonazepam 3 mg and start 2 mg w/ (with) half. V11 stated, On 2/7/23, I (V11) ordered it stat. When the man from the pharmacy came up, (R1) was being sent out to the hospital. When asked about Clonazepam being a controlled substance, V11 stated, I (V11) can't get (Clonazepam) medication without a script (signed prescription). This surveyor asked V11 when V11 documented changing R1's Clonazepam order to 2 mg tablets on 2/6/23, why was there a delay with R1's Clonazepam 2 mg tablets getting delivered to the facility on 2/7/23. V11 stated, (V6) was probably out of the building. I (V11) could not get the script. I (V11) endorse to night nurse. I (V11) knew I (V11) would be here the next day (on 2/7/23) and had to get it taken care of. R1's Order Summary Report, documents, in part, an order of Clonazepam Oral Tablet 2 mg. Give 3 mg by mouth two times day for seizures. Give one and half tablet to equal 3 mg (start date of 2/6/23). In R1's Nurses Note, dated 2/6/23 at 5:05 pm, V11 documented, (R1) has allergy to blue dye in which one of (R1's) medications contains it. Writer (V11) called the pharmacist, and she recommended giving (R1) a 2 mg tab and half because its white and it won't affect allergy. On 3/14/23 at 12:57 pm, V11 (LPN) stated that V11 was R1's primary nurse on 2/7/23 when V11 witnessed R1's seizure in R1's bed from 2:27 pm to 2:33 pm. V11 stated that 911 emergency services were called and that R1 was transferred emergently to the hospital on 2/7/23 after R1's seizure. In R1's Nurses Note, dated 2/7/23 at 4:43 pm, V11 documented, in part, that V11 was called to R1's room by a physical therapist where V11 observed (R1) experiencing a seizure. Seizure started at 2:27 and lasted until 2:33 (pm) . Once seizure stopped, (R1) was unresponsive with eyes open. 911 called . Ambulance took (R1) to (local hospital) for eval (evaluation) at 2:45 (pm). R1's prescription (paper) for Clonazepam Oral Tablet 2 mg. Give 3 mg by mouth two times day for seizures. Give one and half tablet to equal 3 mg with an order date of 2/7/23 was signed by V6 (NP) for a 2 week supply. On 3/14/23 at 10:18 am, V6 (Nurse Practitioner, NP) stated that due to R1's allergy to blue dye in medications, V6 did change the Clonazepam from 1 mg tablets which were blue to the 2 mg tablets which were white pills. V6 stated, V6 will sign paper prescriptions when nursing staff needs medications ordered or reordered that require a nurse practitioner or physician's signature. V6 stated, within the EMR, the nurse will hit print script button, and the paper prescription will print in the facility where V6 will then sign the medication prescription. V6 stated, once or twice there was a problem with the printer in the facility where the prescription wouldn't print for V6 to sign. V6 stated , V6 was asked by V11 to sign R1's prescription for changing the Clonazepam dosage due to R1's allergy. V6 stated, V6 signed the new Clonazepam prescription on the same day that V11 asked for V6 to sign it (2/7/23) and was informed that for 2 days, R1 had not been taking the Clonazepam (due to blue dye allergy). V6 stated, the nursing staff had called the primary NP (V18) to get the new Clonazepam prescription signed, but that it was not signed yet. V6 stated, I (V6) wasn't aware. They (nurses) were telling me (V6) that they were trying to contact primary. I (V6) don't know to ask. I (V6) was not notified that (R1) wasn't getting the medication (Clonazepam). They (nurses) asked me 'Can you sign this' for (R1's) seizure medication (Clonazepam). When asked if R1 is not receiving a seizure medication, could this cause R1 to have a seizure, Yes. It could cause (R1) in having a seizure, when (R1's) missing medication. Upon this surveyor reviewing R1's MAR from February 2023, no documentation of nurses administering R1's Clonazepam 3 mg orally twice a day for seizures is noted from R1's re-admission to the facility on 2/5/23 to R1's hospitalization on 2/7/23 for a seizure in the facility. R1's Care Plan, with admission date 2/3/23, documents, in part, a focus of (R1) has a seizure disorder with an intervention of give seizure medications as ordered by doctor. On 3/15/23 at 3:38 pm, V18 (Primary NP) stated that V18 saw R1 twice in the facility. This surveyor informed V18 that R1 was ordered for Clonazepam from the hospital with an original dose in 1 mg tablets that were blue in color. When asked if nursing staff notified V18 of this, V18 stated, I (V18) don't recall that. When residents come from the hospital each time, I (V18) tell the nurses to follow on discontinued hospital medications. When asked since R1 was ordered for Clonazepam and the dose needed to be changed due to R1's blue dye allergy (to change Clonazepam from blue to white color tablets), did V18 write or sign a prescription for R1's new Clonazepam order, and V18 stated, No, I (V18) didn't write the script. I (V18) confirm the orders over the phone with the nurse. I (V18) don't have a fax at home. And I'm (V18) in the clinic once a month. I (V18) don't have the access to send to a script to pharmacy for controlled substances. This surveyor informed V18 that R1 was ordered for Clonazepam for seizures. V18 stated, I (V18) am not aware of that. That (R1) was on Clonazepam for seizures. I (V18) tell the nurses for anything medical, follow everything with the hospital. If it's a medication for psych, then call the psych doctor for clarification. On 3/15/23 at 1:43 pm, V2 (Director of Nursing, DON) stated that Clonazepam is a controlled substance and that the nurse must have the paper prescription signed to be faxed to the facility's pharmacy. V2 stated that during the day shift, the in-house NP can sign any prescription for controlled substances. V2 stated nurses can remove emergency medication from the facility's emergency medication dispensing machine if needed. V2 stated, the process for administering meds is for the nurse to verify the dosage and medication name; use aseptic technique; determine proper way to administer (crushed or whole); and then document in EMAR that medication is given. V2 stated, a check mark will appear on the EMAR when the nurse administers the medication, or the nurse will document a chart code if nurse is not able to give medication for whatever reason. On 3/15/23, V2 provided this surveyor a list of the emergency medications housed in the emergency dispensing machine in the facility, and Clonazepam is not on the emergency medication list. Facility policy, titled Pain Assessment and Management and dated 1/2/22, documents, in part, Purpose: The purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . Implementing Pain Management Strategies: 1. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: . b. Physical - ice packs, cool or warm compresses. Facility policy, titled Documentation of Medication Administration and dated 3/1/22, documents, in part, Policy heading: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse . shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. Facility policy, titled Medication Orders and dated 6/2/22, documents, in part, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders . Recording Orders: 1. Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. Facility policy, titled Controlled Substance and dated 3/1/22, documents, in part, Controlled Substances. Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling , storage, disposal and documentation of controlled medications. Policy Interpretation and Implementation: . 9. c. An individual resident controlled substance record is made for each resident who is receiving a controlled substance. Facility policy, titled Resident Rights and dated 2/1/23, documents, in part, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . jj. equal access to quality care. Facility job description titled Licensed Practical Nurse, (LPN) and dated 4/1/17, documents, in part, Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Supplies: . Prepare & administer medications as ordered by the physician. If a medication is unavailable, the physician is to be notified for further instruction and potential follow up orders . Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision to a resident who was assessed as a high fall risk which resulted in a fall. This failure affected one resident (R2) of three residents (R2, R3, R4) reviewed for falls in the facility. Findings include: R2's admission Record, documents, in part, that R2's diagnoses include encephalopathy, epilepsy, contracture of muscle, unsteadiness on feet, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2's Brief Interview for Mental Status (BIMS) score is a 12 which indicates that R2 is has moderate cognitive impairment. R2's Functional Status for Functional Limitation in Range of Motion for upper extremity is coded as 1 which indicates impairment on one side and for lower extremity is coded as 2 which indicates impairment on both sides. R2's Order Summary Report documents, in part, the following order: (R2) may use (reclining wheelchair) for mobility (12/30/22). R2's Fall Risk Assessment, dated 2/3/23, documents, in part, a score of 75 which is the category of High Risk for Falling with a history of previous falls. In R2's Nurses Notes, on 3/7/23 at 8:00 pm, V5 (Licensed Practical Nurse, LPN) documents, in part, Writer was notified that (R2) slide off (R2's) wheelchair to the floor. Stated, '(R2) slide from my wheel chair.' (R2) was assessed. On 3/15/23 at 12:23 pm, R2 stated, on 3/7/23, R2 was in R2's reclining wheelchair in the dining room (day room) for dinner service. R2 stated that R2 was dozing off and that R2 was leaning to one side and R2 was sliding steadily out of the chair. R2 stated, R2 was yelling, Help, help, from the dining room to get staff's attention due to no staff member present in the dining room. R2 stated, R2's feet were touching the floor and that R2's upper body was still partly in the reclining wheelchair. R2 stated, R2 couldn't remember the time lapse of how long R2 waited for staff assistance but staff didn't respond quickly. R2 stated, V5 (LPN) came into the dining room and that V3 (Certified Nursing Assistant, CNA) came after V5 called for V3 to come help. On 3/16/23 at 12:37 pm, V3 (CNA) stated that V3 was assigned as R2's CNA on the evening shift (3:00 pm - 11:00 pm) on 3/7/23. V3 stated that for dinner time on 3/7/23, R2 was moved by another staff member to the dining room in R2's reclining wheelchair. V3 stated, V3 provided R2 the dinner tray and R2 began eating the dinner meal. V3 stated, another resident (R8) who was on R2's floor but is now on another floor did not receive a dinner tray and that I (V3) had to go to the kitchen to get a dinner tray for R8. When asked if V3 informed any staff that V3 was leaving R2's floor, V3 stated, I (V3) didn't let anyone (staff) know. For me, to verbally facilitate that I (V3) am not going to be there on the floor. Honestly, I (V3) didn't tell anyone. I (V3) was gone for 10 minutes. V3 stated, V3 delivered the dinner tray to R8 and returned back to the dining room. When asked who else was in the dining room when V3 returned from the kitchen, V3 stated that there were 3 other residents who needed to be put back to bed but V3 could not recall their names. V3 stated, R2 was in R2's reclining wheelchair and was coming down slowly (in wheelchair). I (V3) had to reposition (R2). I (V3) lifted (R2) up a little but (R2's) heavy. V3 stated, V3 left the dining room to get ready to place R2 back to bed. When asked if R2 was secure in the reclining wheelchair when V3 left the dining room to prepare R2 to get back to bed, V3 stated, Slightly as much. I (V3) put (R2) in position if (R2) where to fall position. I (V3) needed to make a correct position. Surveyor asked V3 if V3 positioned R2's butt back in the reclining wheelchair before V3 left the dining room. V3 stated, No. (R2's) butt was forward, and (R2) was leaning to the right with (R2's) upper body. V3 stated, I (V3) got ready to put (R2) back to bed. I (V3) was looking as well for someone to help (staff). I (V3) had went back to area by dining room. I (V3) was in room [ROOM NUMBER], I (V3) had responded to what was needed. V3 further stated, I (V3) heard (V5) saying, 'Where are the CNAs. (R2) has fallen.' Surveyor asked V3 what was V3 doing after V3 left R2 unattended in the dining room. V3 stated, I (V3) was looking for the (mechanical) lift. It is usually on the 3rd floor, but I (V3) saw it down the hallway. I (V3) then was making up (R2's) bed in (R2's) room. I (V3) slowly coming back to day room, and the call light was on in room [ROOM NUMBER], so I (V3) was chatting with (the resident) for a moment. I (V3) heard 'Help' from (V5). I (V3) was looking for help. I (V3) did three things when I (V3) left (R2). 1) Find people to help, 2) Get (mechanical) lift, 3) Make up (R2's) bed. When asked if V3 found help from other staff members on the floor, V3 stated, No, (V16 and V17 CNAs) were changing other people, and it was shift change. This surveyor asked if V3 asked a nurse for help, and V3 stated, I (V3) don't keep track of what the nurses are doing. That's not my responsibility. Surveyor asked V3 if there were any staff in the day room after V3 repositioned R2 in the reclining wheelchair and then left R2 in the dining room, V3 stated, There was no staff in the day room. On 3/14/23 at 1:52 pm, V5 (LPN) stated that on 3/7/23 at 7:20 pm, V5 was getting ready to give report to the oncoming night shift nurse when V5 heard shouting from the dining room. V5 stated, R2 had slid out of R2's reclining wheelchair and was shouting for help. V5 stated, V5 then called out for help from other staff and that V3 came from room residents room near the dining room. V5 stated, R2's lower body was on the floor but that R2's upper body and head were still on the reclining wheelchair. V5 stated, V5 assessed R2 and that V3 and V5 then carefully placed R2's entire body on the floor. V5 stated, V16 and V17 (CNAs) then came into the dining room to assist with transferring R2 via mechanical lift to the reclining wheelchair. On 3/15/23 at 1:43 pm, V2 (Director of Nursing, DON) stated, R2 is approved for a reclining wheelchair and that R2's buttocks should be positioned directly on the seat of the chair with the head at 30 degrees and legs up on the recliner leg pad. V2 stated, V3 did state to V2 that V3 did leave R2 in the dining room to get another resident's tray. V2 stated, staff should maintain fall risk interventions by supervising and frequently monitoring residents to prevent falls. R2's Care Plan, with revision date of 5/14/21, documents, in part, a focus of (R2) is high risk for falls with interventions of place resident back in bed after dinner and purposeful rounding at least every hours. Anticipate and meet the resident's needs. Facility document, untitled and undated, documents, in part, that R2's fall occurred on 3/7/23 at 7:50 pm with an intervention of 3/7/23, staff will monitor and reposition resident as needed to prevent sliding. Facility document, titled Fall Risk Identifiers and undated, documents, in part, . All nurses and CNAs are responsible for providing supervision and a safe environment. Facility policy, titled Falls and Fall Risk, Managing and dated 7/1/22, documents, in part, Policy Heading: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Definition. According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of overwhelming force . Fall Risk Factors: . 2. Resident conditions that may contribute to the risk of falls include: . c. cognitive impairment . e. lower extremity weakness . i. functional impairments . Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff . will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Facility policy, titled Fall Risk Assessment and dated 7/1/22, documents, in part, 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. Facility job description titled Certified Nursing Assistant and dated 3/24/16, documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential duties and responsibilities: . Provide assistance with serving meals and feeding . Provide assistance in ambulating, turning, and positioning residents . Adhere to professional standards, company policies and procedures, and all federal, state, and local requirements.