**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) The facility's grievance log dated 10/25/2024 documents: R25 reported to manager (V10 Restorative Registered Nurse) that (R25) had money missing. V29 SSD (Social Service Director) followed up and R25 explained that last week (R25) had $100 missing and then on October 22nd (R25) had another $20 missing. He stated the money was in his wallet in his top drawer. V29 reported R25's missing money to V1 Administrator to follow up. R25's MDS (Minimum Data Set) dated 8/19/24 documents R25 is alert and oriented. On 10/27/24 at 9:58 AM, R25 stated I have had money missing twice. R25 explained, two weeks ago R25 had $170 in cash in R25's wallet, which was in the top drawer of R25's nightstand. R25 left his room to attend therapy, leaving the wallet in the nightstand drawer, and upon returning to R25's room, R25 found that the $100 bill was gone leaving $70 in the wallet. R25 stated he reported the theft to the unidentified Certified Nurses Assistant (CNA) and Registered Nurse (RN), but doesn't remember who it was. R25 stated again on 10/23/24, R25 had money stolen. R25 explained that R25 left the facility for a physicians appointment and while en route, realized he had forgotten his wallet. Upon returning to the facility, R25 noticed that the top drawer of the nightstand was open a couple inches and another $20 was missing, leaving $50 in the wallet. R25 reported this theft to the unidentified RN on duty. R25 stated that V29 SSD informed R25 that four to five people have been hit in the last couple of weeks and that the facility is looking into the thefts. On 10/28/24 at 10:39 AM, V29 SSD confirmed that R25 had reported having money stolen but that V29 was not made aware of the allegation until 10/25/24 On 10/28/24 at 10:45 AM, V1 Administrator confirmed V1 was aware of R25's missing/stolen money. On 10/28/24 at 11:29AM, V10 Restorative Registered Nurse stated R25's missing money was reported to her by V6 Certified Nurses Assistant (CNA) on 10/23/24. V10 explained that V10 reported the missing/stolen money to V1 Administrator and V2 Director of Nursing (DON) on 10/24/24. On 10/28/24 at 11:40 AM, V6 CNA stated R25 came to the nurses' station and stated loudly this is the second time someone stole from me! On 10/30/24 at 10:00 AM, V25 LPN (Licensed Practical Nurse) stated V25 is familiar with R25 and has seen cash in a money clip on R25's wallet. On 10/30/24 at 10:10 AM, R25 stated R25 had been given the money by his family explaining his son or daughter will bring him cash whenever he needs it. 4.) The facility's grievance log dated 10/25/24 documents R46 had money stolen on 10/1/24. On 10/27/24 at 9:50 AM, R46 stated R46 had cash stolen from R46 during a room move. R46 explained R46 had $100 in cash in R46's dresser drawer and after moving rooms, the $100 was missing. R46 stated an unidentified housekeeper saw the cash in R46's drawer while assisting R46 with the room move. R46's MDS (Minimum Data Set) dated 9/11/24 documents R46 is alert and oriented. R46's ongoing Census Sheet documents R46 changed rooms on 10/01/24. On 10/28/24 at 10:39 AM, V29 SSD confirmed R46 reported having money stolen and reported it to V29 on 10/25/24. V29 reported that V29 completed a Grievance Form and that V1 Administrator was handling the investigation. On 10/28/24 at 10:45 AM, V1 Administrator confirmed V1 was made aware of R46 having money stolen and that the facility was handling it internally. On 10/28/24 at 11:40 AM, V6 CNA (Certified Nursing Assistant) stated on 10/23/24, R46 reported to V6 that R46 had money stolen. On 10/29/24 at 11:40 AM, V16 LPN (Licensed Practical Nurse) stated R46 reported to V16 that R46 had money stolen from him. On 10/30/24 at 10:15 AM, R46 stated that R46 gets cash out of the ATM (Automated Teller Machine) using a debit card from his Social Security Card, therefore he does not have any bank statements. Based on observation, interview and record review the facility failed to protect the resident's right to be free of misappropriation of money and personal property for four of five residents (R13, R130, R25 and R46) reviewed for misappropriation in a sample list of 40 residents. Failing to prevent the misappropriation of R13's commemorative coin set, which is not replaceable, resulted in R13 being tearful and experiencing feelings of sadness and loss due to the sentimental value of the coins. Findings Include: The facility Abuse Prevention Program dated October 2022 documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. 1. R13's Care Plan updated 10/27/24 documents: (R13) has an alteration in neurological status related to: Major Depressive Disorder Recurrent, Agoraphobia, Anxiety, and PTSD (Posttraumatic Shock Disorder). R13's Minimum Data Set (MDS) dated [DATE] documents R13 is cognitively intact. On 10/29/24 at 9:00AM R13 was seated in a wheelchair in R13's room with a family member visiting. R57 (R13's) roommate was in bed in the room. R13 stated I can talk to you in front of my roommate and my (family member) I trust them. I had $100.00 and eight double struck commemorative coins taken from my lock box. It had to be staff because they might have known I was keeping my key beside my bed in my pencil box. It is bad enough I lost the money, but I used to carve the casts and strike the coins. Those I had here were in silver and bronze. I am losing my sight and my fingers don't work well because I have neuropathy. Those coins meant a lot to me. I kept them here because I like to look at them and remember what I used to do. I can't remember the exact date, but my (family member) can tell you. I reported it to (V1) Administrator and (V29), Social Services. They did not offer to call the police, but I wish they had. R13 looked upset and bit his bottom lip as he talked. Tears started to well up in R13's eyes. V33, R13's family member stated (R13) had the coins and his $100.00 on the evening of 10/16/24. I saw them. I came back on 10/17/24 and he did not have them. R57 stated I did not see (R13's) coins that day before, but I have seen that (R13) had the coins he made. On 10/29/24 at 11:00AM V1, Administrator stated there is really no documented investigation. I do not believe the money has been returned to (R13). 2.) The facility's Grievance Log for the three months prior to the survey documents R130 withdrew money from the bank on 9/1/24 and stored it in her purse. On 9/2/24 (R130) noticed money was missing around noon. (R130) was interviewed and family confirms money was withdrawn from the bank. Facility will replace the money. R130's MDS dated [DATE] documents R130 is cognitively intact. R130's Progress Note documents R130 was discharged home with home care services 10/28/24. On 9/30/24 R130 stated I took $140.00 out of the bank and put it in my purse. I went to therapy and when I came back I was going to address cards to my family and put in the money but the money was gone. I never got the money back. I told (V34) Care Plan Nurse the money was missing. I never heard anything so I just thought I would still be getting it. I have been sick and that was quite a bit of money to me. Now that I am home, I will be a little short at the end of the month and it was for my family. I save that up. You know I think whoever took it must really need it, but I would have just given it to them if they asked. On 10/30/24 at 12:00PM V34 verified R130's account of the allegation. V34 stated I really thought (R130) had the money replaced. on 10/30/24 at 12:15PM V29, Social Service also verified R130's account of the allegation. V29 also stated she was under the impression R130 was reimbursed for this loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete weekly pressure ulcer assessments, implement treatment orders timely, administer treatments as ordered, maintain wound dressings, accurately complete skin and wound assessments, and implement interventions to prevent the development and worsening of pressure ulcers for four (R8, R32, R52, R44) of four residents reviewed for pressure ulcers in the sample list of 46. These failures resulted in R8 developing stage three pressure ulcer and R32 developing an unstageable pressure ulcer. Findings include: The facility's Measurement of Alterations in Skin Integrity policy dated January 2017 documents wound type, stage, measurements and characteristics should be assessed and documented upon identification and weekly thereafter, record refusal of treatment or pressure relieving interventions and the resident's care plan should also reflect this. The facility's Braden- Pressure Risk Assessment Tool policy dated January 2017 documents the Braden scale determines pressure ulcer risk and this assessment should be completed upon admission, then weekly for the first month, and then at least quarterly and with changes in condition. This policy documents appropriate individualized interventions should be implemented and documented on the resident's care plan. The facility's Pressure/Skin Breakdown- Clinical Protocol dated January 2017 documents to determine a resident's significant risk factors for developing pressure ulcers, such as immobility, recent weight loss, and a history of pressure ulcers; assess skin condition, pain, mobility, treatments, support surfaces, and diagnoses; and the physician will give orders for wound care including pressure redistribution surfaces. The facility's Prevention of Pressure Wounds policy dated January 2017 documents pressure injuries are usually due to sitting in the same position for an extended period of time causing increased pressure, decreased circulation, and subsequent tissue destruction; and can also be related to irritating substances on the skin such as urine and feces. This policy documents there should be a system or procedure in place to assure assessments are completed timely, changes in condition are identified, evaluated, reported to the physician, and addressed. This policy documents preventative measures include repositioning at least every two hours, determining if a special mattress is needed, use of pressure relieving cushions for chairs, avoiding donut shaped or waffle cushions, routinely assessing skin condition, using moisture barrier creams, using pillows to float heels when in bed, immediately reporting any signs of pressure injuries, administering vitamins and supplements per physician's orders, and having the dietitian assess nutrition and make recommendations. 1.) R8's Minimum Data Set (MDS) dated [DATE] documents R8 is cognitively intact, requires partial/moderate staff assistance for rolling in bed, requires substantial/maximal staff assistance for transfers, and is occasionally incontinent of urine. R8's Braden assessment dated [DATE] (after R8's pressure ulcers developed) document R8 is low risk. The last Braden Assessment recorded for R8 was on 10/13/23. R8's Care Plan dated 5/26/23 documents R8 is at risk for impaired skin integrity, and includes interventions to apply barrier cream three times daily as needed, Braden Assessments weekly for four weeks then quarterly, and to encourage good nutrition and hydration to promote healthier skin. There is no documentation that R8 refuses turning/repositioning. This care plan has not been updated to include R8's pressure ulcers or any new pressure relieving interventions after 5/26/23. R8's Physician Order dated 6/19/23 May use Pressure relieving mattress and/or cushion on w/c (wheelchair) if Needed. There is no documentation that R8 requires a pressure relieving cushion in R8's wheelchair. R8's ongoing weight log documents R8 had a significant weight loss between August 2024 and September 2024, and continued weight loss as of 10/30/24. R8's October 2024 Treatment Administration Record (TAR) documents an order dated 10/6/24 to cleanse right buttock wound with wound cleanser, apply collagen and bordered foam every shift for Stage Two pressure ulcer, and an order dated 10/10/24-10/28/24 to clean right buttock wound, apply Santyl, apply Calcium Alginate, and cover with a bordered foam dressing daily. This TAR documents to complete skin assessments on Mondays and Thursdays, and inaccurately documents R8's skin as intact and without wounds 10/7-10/14/24. This TAR documents to apply barrier cream to the left buttock three times daily as of 10/7/24, and there is no documentation that barrier cream was applied prior to 10/7/24. R8's Nursing Note dated 10/6/24 at 12:12 AM documents R8 had a new Stage Two Pressure Ulcer to the right buttock, the Wound Nurse (V12) was notified, the area was cleansed, Collagen was applied, and the wound was covered with a bordered foam dressing. There is no documentation of wound characteristics and measurements prior to evaluation by V7 Wound Physician on 10/7/24. R8's Wound Care Telemedicine Follow Up Evaluation dated 10/7/24, recorded by V7, documents R8 has a Group 1 mattress and a foam cushion in R8's chair. This note documents R8 has a right buttock Stage Three Pressure Wound of greater than three days duration that measured 1.5 centimeters (cm) long by 1.7 cm wide by 0.2 cm deep and had 90% slough (dead cells). This note includes recommendations to off-load wound, reposition per facility protocol, Group 2 Mattress (air mattress), Multivitamin once daily, Vitamin C 500 milligrams (mg) twice daily, Zinc Sulphate 220 mg once daily for 14 days. There is no documentation in R8's medical record that the recommended vitamins were implemented. R8's Wound Care Telemedicine Follow Up Evaluation dated 10/18/24 documents R8's right buttock wound resolved and R8 had a left hip Stage Three Pressure Wound of greater than two days duration that measured 1.3 cm by 1 cm by 0.2 cm and had 50% slough. This note documents R8 now has a Group 2 mattress as of today (11 days after V7's order) and recommends to off-load wound and repositioning. R8's Wound Care Telemedicine Follow Up Evaluation dated 10/25/24 documents R8's left hip Stage Three Pressure Wound measured 1.2 x 1 x 0.2 cm, and R8's right buttock Stage Three Pressure Wound reopened over three days ago and measured 2.0 x 2.0 x 0.3 cm. There is no documentation in R8's medical record that R8 has been evaluated by a dietitian since March 2024, prior to R8's weight loss and wounds. On 10/27/24 at 8:30 AM and 11:58 AM R8 was sitting in a wheelchair near the nurses' station with a soft lap cushion looped through the armrests of R8's chair. at 10:18 AM R8 was sitting in a wheelchair in the dining room. At 11:58 AM R8 was sitting in her wheelchair. R8 stated R8 has wounds on R8's bottom, but was unsure how long the wounds had been there or how often treatments are administered. On 10/28/24 at 9:21 AM R8 was sitting in a wheelchair by the nurses' station. At 10:38 AM R8 was sitting in a wheelchair in the dining room. At 11:13 AM staff transported R8 in a wheelchair from the dining room to the 100 hall nurses' station. Continuous observations were made from 11:13 AM until 11:39 AM of R8 sitting in a wheelchair near the nurses' station. The lap cushion remained in place during all of these observations. On 10/28/24 12:02 PM V4 and V6 Certified Nursing Assistants (CNAs) transferred R8 from her wheelchair into bed. There was a foam horseshoe shaped cushion, that was approximately one inch thick, in R8's wheelchair. R8 was incontinent of urine and V6 provided incontinence cares. R8 had open pink wounds to the right buttock and left hip that were not covered with dressings. V6 stated V6 had not provided any cares for R8 yet today and was unsure how long the wounds were without dressings. V6 stated V6 will notify the nurse so the wounds can be covered. On 10/28/24 at 12:16 PM V3 Licensed Practical Nurse stated R8's wounds started with the right buttock that was a thin layer of skin that had sheered off, and then a few days later the left hip wound developed. V3 entered R8's room, administered R8's pressure ulcer treatment, and used pillows to position R8 on her right side before leaving the room. V3 stated no staff had reported that R8's dressings came off, prior to V6. On 10/28/24 at 2:34 PM V11 CNA stated V11 R8 was transferred out of bed around 7:30 AM and V11 provided no other transfer or toileting cares for R8 prior to leaving at 10:00 AM. V11 stated V4 was the only other CNA working on R8's hall at that time. On 10/28/24 at 3:04 PM V4 CNA stated V4 did not provide any cares for R8 besides the transfer observed at 12:02 PM. On 10/28/24 at 3:23 PM V12 Wound Nurse stated V12 has been the facility's wound nurse for approximately three weeks. V12 stated V12 has not yet updated resident care plans to include wounds, but they should be updated to reflect wounds and new interventions. V12 stated V12 and V7 Wound Physician complete weekly wound assessments which are documented in the assessment section of the resident's electronic medical record (EMR) or in V7's notes. V12 stated there can't be a delay in starting treatment, and the nurses should notify the physician and document an assessment of the wound when found. V12 confirmed Braden assessments are documented in the assessments section of the EMR, and should be done on admission, then weekly for four weeks, and then quarterly. V12 stated residents at high risk for pressure ulcers should have weight monitored weekly, placed on a turning and repositioning schedule, and skin checks more than weekly. V12 stated turning/repositioning should be documented on the care plan and in tasks in the EMR. V12 stated residents with wounds should be referred to the dietitian. At 4:00 PM V12 Wound Nurse stated V12 rounds with V7 Wound Physician, and V12 is responsible for entering V7's orders/recommendations. V12 stated R8 used to walk and then recently declined requiring total assistance for cares. V12 stated staff should reposition R8 at least every two hours and offload pressure from R8's wounds. V12 stated That is way too long for (R8) to be in her wheelchair, when told R8 had not been repositioned from 7:30 AM until 12:00 PM. V12 stated R8's air mattress was installed on 10/18/24. V12 stated V12 was unsure when R8's wheelchair cushion was implemented. V12 was unaware of V7's recommendations for Vitamin C, Zinc and Multivitamin, and confirmed these recommendations were never implemented. On 10/29/24 at 12:18 V12 confirmed V12 had not notified the dietitian of residents with wounds, and confirmed all of V7's wound notes were uploaded into R32's electronic medical record. On 10/30/24 at 11:05 AM V12 stated V12 was unable to determine the type and brand of R8's cushion, so the cushion was replaced today. On 10/29/24 at 11:57 AM V2 Director of Nursing stated V2 used to oversee wounds until June 2024. V2 stated the wound nurse is responsible for sending a wound list to the dietitian. On 10/29/24 at 12:34 PM V19 Registered Dietitian stated R8's last nutritional assessment was completed in March 2024. V19 stated the facility does not notify or request for V19 to evaluate residents with wounds. V19 stated V19 runs reports to determine which residents need to be evaluated, but there is no report that identifies wounds. V19 stated V19 has to ask staff to determine if residents have wounds. V19 stated no one had requested to evaluate R8's nutritional status and V19 was unaware that R8 had developed pressure ulcers. V19 stated if V19 had evaluated R8, V19 would have recommended Zinc, Vitamin C, a multivitamin, and liquid protein; and possibly would have recommended a nutritional supplement if R8 had lost weight, but R8 does not have a documented weight for October. On 10/29/24 from 1:00 PM-1:15 PM V7 stated V7 has been the facility's wound physician for the last few months and V7 conducts her visits virtually, not in person. V7 stated Prealbumin is ordered to evaluate nutrition and protein levels and should be implemented by the next month's laboratory draw. V7 stated vitamins aid with wound healing and should be implemented by the next day. V7 stated Group 1 mattresses are foam mattresses that are good for up to Stage Two Pressure Ulcers and a Group 2 mattress is a low air loss mattress used for Stage Three Pressure Ulcers and higher, or if the resident has a low Body Mass Index. V7 stated residents at high risk for pressure ulcers should have preventative interventions implemented based on the facility's protocol, which generally includes frequent repositioning and offloading and use of pressure relieving surfaces. V7 stated V7 avoids using horseshoe or donut cushions since they cause skin to spread and can cause wounds to worsen. V7 stated generally foam cushions with approximately three inch thickness are used. V7 stated there was a period of time where the facility didn't have a wound nurse due to staffing issues; V7 worked closely with V2 when V2 was the Assistant Director of Nursing, but then V2 changed positions and there were several weeks where no one was assessing wounds. V7 confirmed not implementing pressure relieving interventions, physician recommendations, nutritional evaluations, wound and skin assessments/monitoring, and treatments timely and as ordered, can contribute to the development and worsening of pressure ulcers. 2.) R32's MDS dated [DATE] is inaccurate and documents R32 did not have pressure ulcers. R32's MDS dated [DATE] documents the following: R32 has sever cognitive impairment, R32 requires supervision/touch assistance from staff for bed mobility, and partial/moderate staff assistance with transfers. R32 is occasionally incontinent of urine and requires dependence on staff for toileting hygiene. R32 had an unplanned significant weight loss within the last six months. R32 has two facility acquired pressure ulcers, one stage three and one unstageable. R32's Braden assessment dated [DATE] documents R32 scored low risk for developing pressure ulcers. There are no other documented Braden Assessments in R32's medical record until 10/8/24, after R32 developed unstageable and stage three pressure ulcers. R32's Care Plan dated 7/9/24 documents R32 has potential for impaired skin integrity and includes interventions to apply barrier cream three times daily as needed, Braden scale weekly for four weeks then quarterly, encourage good nutrition and hydration, follow physician's orders for treatment. This care plan has not been updated to include R32's pressure ulcers or any new pressure relieving interventions after 7/9/24. There is no documentation that R32 refuses pressure relieving interventions. R32's Physician's Order dated 7/11/24 documents to give Pro Stat (protein supplement) 30 milliliters once daily. R32's Physician Order dated 7/9/24 documents to apply pressure relieving boots or offload heels when in bed. R32's Physician Order dated 7/31/24 documents air mattress to bed. R32's Physician Order dated 7/12/24 documents May use pressure relieving mattress and/or cushion on w/c if Needed. There is no documentation that barrier cream, air mattress, or wheelchair cushion was applied prior to these orders. R32's admission Evaluation dated 7/3/24 documents R32 admitted with a Stage Two Pressure Ulcer of sacrum/coccyx. There is no documentation that a treatment order was initiated for this wound until 7/9/24 and there are no documented assessments of this wound until 7/31/24 when the wound had deteriorated to a Stage Three. There is no documentation that R32 admitted with any foot wounds. R32's Shower Sheet dated 7/7/24 documents R32 had a blister to the left heel and left big toe. There are no documented measurements or wound descriptions, and no documentation that the physician was notified and a treatment was initiated prior to 7/9/24. R32's Nursing Note dated 7/9/2024 at 12:34 PM documents R32 had a blister to the left heel that measured 3.5 cm by 7 cm, a skin protectant and dry dressing was applied, R32's buttocks was red/excoriated with no open areas. An antifungal cream and zinc oxide cream was applied. R32's Nursing Note dated 8/4/2024 at 5:29 PM documents R32's coccyx had a 6 cm by 3 cm maroon spot with a small open area. Triple antibiotic ointment and a bordered foam dressing was applied and education was provided on timely depend changes and cream application. R32's Registered Dietitian Note dated 8/29/24 at 8:07 AM documents R32's weight has decreased over the past month and there were no new interventions. This note does not document that the dietitian was aware of R32's stage three pressure ulcers and there is no documentation that R32 was evaluated by a dietitian in September. There are no weekly wound assessments in R32's EMR prior to October 2024, besides V7's assessments on 7/31/24, 8/9/24, 8/15/24, 9/5/24, and 9/12/24. R32's Wound Care Telemedicine Initial Evaluation dated 7/31/24, recorded by V7, documents R32's unstageable Deep Tissue Injury of the Left Heel measured 6.9 cm by 4.4 cm and no measurable depth. and R32's Stage Three Pressure Ulcer of the coccyx measured 1.9 cm by 1 cm by 1.2 cm. V7 recommended to off-load wound, reposition per facility protocol, float heels in bed, pressure relieving boot, dietitian consult, and Prealbumin level. There is no documentation that R32's Prealbumin level was obtained as recommended and V7 documents Prealbumin results pending on V7's Evaluations from July-October 2024. R32's Wound Care Telemedicine Evaluation dated 10/25/24 documents R32's unstageable heel ulcer measured 1.0 x 0.7 x 0.2 cm, the wound was macerated (moisture related damage), and the treatment was changed to Calcium Alginate with bordered foam dressing applied three times weekly. R32's Stage Three Pressure Ulcer of the coccyx measured 1.0 x 0.5 x 0.5 cm. R32's August and September 2024 TAR documents R32's left heel treatment scheduled three times per week was not administered three times in August and five times in September. R32's daily coccyx treatment was not administered eight times in August and eight times in September. On 10/27/24 at 11:44 AM R32 stated R32 has sores on her feet/heel and her bottom that R32 did not admit with. R32 was lying in bed on her back and was not wearing heel protectors. R32's heels were in direct contact with R32's air mattress. R32's wheelchair pressure relieving cushion decompressed with applied hand pressure and the wheelchair seat could be felt through the cushion, indicating the cushion was not fully inflated with air. On 10/27/24 at V8 CNA stated V8 was unsure if R32 has any foot wounds, but R32 has a wound on R32's bottom. V8 stated R32 wears pressure relieving boots at night. V8 tested R32's wheelchair cushion with hand pressure and confirmed the cushion decompressed. V8 stated I believe that is how it (cushion) is suppose to be. On 10/28/24 at 9:03 AM R32 was sitting in her wheelchair in her room. At 11:20 AM staff brought R32 to her room and R32 was still in her wheelchair. R32 remained sitting in her wheelchair in her room until 11:45 AM when V4 CNA transferred R32 onto the toilet. At 11:54 AM V5 CNA responded to R32's bathroom call light. V5 confirmed R32's wheelchair cushion was not fully inflated by testing it with applied hand pressure. V5 stated that is how much it has been inflated since R32 started using it. V5 transferred R32 off of the toilet and into R32's wheelchair containing the cushion. On 10/28/24 at 11:59 AM V4 stated V4 transferred R32 out of bed and into her wheelchair between 8:00 AM and 9:00 AM. At 12:01 PM V4 and V5 transferred R32 into the stationary chair in R32's room and the chair did not contain a pressure relieving cushion. At 12:31 PM and 1:20 PM R32 was still sitting in the stationary chair. On 10/28/24 at 12:31 PM V3 Licensed Practical Nurse stated V3 already completed R32's heel treatment earlier this morning and V3 had applied a medicated honey treatment. V3 stated V3 wasn't aware that R3's heel treatment had changed to calcium alginate, so V3 will need to do R32's heel treatment again. At 1:36 PM V3 stated skin assessments are documented on the Medication Administration Records, the nurse documents if skin is intact, or if there is a wound or new wound. V3 stated there should be wound descriptions in the progress notes. V3 confirmed CNAs should use the care plan to determine pressure relieving interventions. V3 entered R32's room, transferred R32 from the stationary chair into bed, and administered R32's left heel and coccyx wound treatments. R32's stationary chair did not contain a pressure relieving cushion. R32's left outer heel had a small superficial wound and there was a deep marble sized wound to R32's coccyx. V3 raised the head of R32's bed, applied R32's covers, and left R32 lying on her back with the head of the bed elevated approximately 45 degrees (causing pressure to R32's coccyx). V3 did not offer or encourage R32 to off-load pressure from her coccyx and lay on her side prior to leaving R32's room. On 10/28/24 at 1:57 PM V3 confirmed V3 did not offer or encourage R32 to lay on her side prior to leaving the room. V3 stated V3 just didn't think of it (off-loading), and confirmed off-loading pressure from the coccyx would aide in wound healing. On 10/28/24 at 3:23 PM V12 Wound Nurse stated R32's wounds are pressure related and interventions include repositioning, off-loading, and pressure relieving boots. V12 confirmed R32 requires staff assistance to reposition or off-load, R32 should be repositioned at least every two hours and pillows should be used to off-load coccyx and heel pressure, unless pressure relieving boots are in place. V12 stated R32 should use a pressure relieving cushion in the wheelchair and stationary chair in her room. V12 confirmed R32's wheelchair cushion should be inflated and you should not be able to feel the seat of the wheelchair when pressure is applied V12 stated the CNAs should be checking that. V12 confirmed nurses should look at the TAR for treatment orders prior to administration and treatment administrations are documented on the TAR. V12 confirmed a blister is a stage two pressure ulcer and not implementing pressure ulcer interventions could contribute to a decline in wounds. V12 confirmed R32 admitted with a stage two pressure ulcer of the sacrum, there is no documentation of left heel wound on admission, and there are no assessments or measurements of this wound prior to being seen by V7. V12 confirmed there are no documented Braden Assessments in R32's EMR after 7/3/24 until 10/8/24. V12 stated a Braden score of 15 is considered high risk and that was R32's score on admission. V12 confirmed Prealbumin was never ordered for R32 and V12 stated she will follow up on this. On 10/29/24 at 9:38 AM V34 MDS Coordinator reviewed R32's admission and nursing notes and MDS, and confirmed R32's July MDS does not accurately reflect R32's skin status at that time. V34 stated V34 was told by staff at that time that R32 did not have any wounds, the wound nurse is suppose to enter wounds into the wound rounds tracking system, but there was no information entered for R32 at that time. V34 stated V34 consulted with corporate and will need to submit a modification for this MDS. V34 stated the wound nurse is responsible for adding wounds and new interventions on the care plan, and pressure relieving boots are documented in physician orders and on the care plan. On 10/29/24 at 12:34 PM V19 Registered Dietitian stated R32 was evaluated in July and August with no new recommendations, but V19 was not aware that R32's wounds had declined when R32 was evaluated in August. V19 stated if V32 was aware, V19 may have increased liquid protein to be given twice daily. V19 stated R32 should have been evaluated again in September, but V19 does not see where that was done. The manufacturer's instructions for R32's pressure relieving cushion dated 5/3/24 documents to inflate air until all of the air cells feel firm, remove the hand pump,allow air to escape from the valve until the air deflation is no longer felt or heard, and then close the inflation valve. Perform a hand check to evaluate sufficient air between the person and the base of the cushion, and adjust as needed. 3.) R44's Minimum Data Set (MDS) dated [DATE] documents R44 is at risk for pressure ulcers and was admitted with no pressure ulcers. R44's Wound Care Telemedicine initial evaluation dated 10/18/24 by V7, Wound Physician documents R44 developed a facility acquired Stage III Pressure Ulcer of greater than 10 days duration on the coccyx measuring 1.6 cm (centimeters) by 1.0 cm by 0.3 cm deep. At that time V7 ordered the following wound dressing: Calcium Alginate with silver covered with gauze island dressing with border. R44's Treatment Administration Record documents this treatment was initiated. R44's Wound Care Telemedicine Follow-up evaluation dated 10/25/24 by V7, Wound Physician documents the wound has increased in size to 3.0 cm (centimeters) by 1.5 cm by 0.5 cm deep. At that time V7 ordered the following wound dressing: medicated honey Calcium Alginate with silver covered with gauze island dressing with border. R44's Treatment Administration Record documents this treatment was not initiated. The treatment ordered 10/18/24 was continued. On 10/29/24 at 1:00PM V12 Licensed Practical Nurse (wound Nurse) applied R44's treatment. V12 removed the old dressing, removed gloves, performed hand hygiene, cleansed R44's wound with normal saline, removed gloves, performed hand hygiene, applied calcium alginate with silver to clean wound bed and covered with a bordered foam dressing. V12 did not apply medicated honey to wound as ordered. When asked why she did not apply the medicated honey V12 stated I don't think that is ordered on the TAR. At this time it was observed R44 had a new Stage III pressure ulcer on her left ischium approximately the size of a quarter. There is no documentation R44 has been evaluated by a dietitian for the facility acquired pressure ulcers. On 10/29/24 at 12:34PM V19 Registered Dietitian stated, When a resident develops a facility acquired pressure ulcer, the facility should reach out to me and I should evaluate and make recommendations to enhance healing. This facility does not do so. I usually pick up on issues like this when I do the periodic visits. I have not evaluated (R44). 4.) R52's Minimum Data Set (MDS) dated [DATE] documents R52 is at risk for pressure ulcers and was admitted with no pressure ulcers. R52's Treatment Administration Record (TAR) for October 2024 documents a new treatment dated 10/26/24 for Clean area to left buttock with normal saline. Apply calcium alginate to wound bed & cover with gauze foam daily every day shift for wound care. On 10/29/24 at 10:00 AM V12 Licensed Practical Nurse (wound Nurse) stated (R52) developed a new facility acquired Stage II pressure ulcer 10/25/24. We are treating it. On 10/29/24 at 1:15PM V12 Licensed Practical Nurse (wound Nurse) applied R52's treatment. V12 removed the old dressing, removed gloves, performed hand hygiene, cleansed R52's wound with normal saline, removed gloves, performed hand hygiene, applied calcium alginate with silver to clean wound bed and covered with a bordered foam dressing. At this time V12 verified R52's wound is now a Stage III because it has visible slough of tissue. V12 also verified R52 has developed an additional dime sized stage III pressure ulcer to her right buttock. R52 was sitting in the bed with the head elevated to sitting position. R52's bed did not have a pressure relieving mattress in place. There is no documentation R52 has been evaluated by a dietitian for the facility acquired pressure ulcers. On 10/29/24 at 12:34PM V19 Registered Dietitian stated, When a resident develops a facility acquired pressure ulcer, the facility should reach out to me and I should evaluate and make recommendations to enhance healing. This facility does not do so. I usually pick up on issues like this when I do the periodic visits. I have not evaluated (R52). There is no documentation to support R52 has been evaluated by the wound care Physician. On 10/29/24 at 1:15PM V12 verified this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R25's ongoing weight logs document R25's weight as 229.6 pounds on 08/01/24 and 216 pounds on 09/02/24, demonstrating a 5.92% weight loss in one month. This log documents R25's October 2024 weight as 215.4 pounds. R25's Nursing Progress Notes dated 9/1/24 - 9/30/24 does not document that V35 R25's Nurse Practitioner or V19 RD (Registered Dietician) were notified of R25's significant weight loss. R25's September and October 2024 Physician Order Sheets do not document any new orders for nutritional supplements following R25's significant weight loss. On 10/29/24 at 11:10 AM, V2 DON (Director of Nursing) stated V2 was unaware of R25's weight loss. V2 stated the expectation is that V19 RD (Registered Dietitian) would report the weight loss to nursing services with their recommendations. On 10/29/24 at 12:31 PM, V19 RD stated that the weight loss from 08/01/24 through 09/02/24 would be considered a significant weight loss. V19 explained the facility should have reached out to V19 so that V19 could have evaluated R25's weight loss and ordered nutritional supplements due to R25's weight loss but the facility does not do that. Based on observation, interview, and record review the facility failed to monitor weights and implement nutritional interventions for significant weight loss for four (R8, R52, R25, R44) of five residents reviewed for nutrition in the sample list of 46. These failures resulted in ongoing weight loss following a significant weight loss for R8, R52, R25, and R44. Findings include: The facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol dated August 2008 documents to assess for recent weight loss and the physician will review for possible causes of weight loss with the nursing staff and/or dietitian before ordering interventions. This policy documents the physician and/or designee will authorize appropriate interventions as indicated, reconsider dietary restrictions and altered diet consistency, and consider diagnostic testing. The facility's Routine Nutritional Documentation and assessment dated 2020 documents residents are assessed and monitored for nutrition in accordance with the Minimum Data Set (MDS) schedule, and residents who are considered with nutritional risk or concerns are referred to the Registered Dietitian for a comprehensive nutritional assessment. This policy documents the Dining Services Manager and Registered Dietitian will document quarterly progress notes for observations, progress of nutritional goals, and nutritional care information. 1.) R8's MDS dated [DATE] documents R8 is cognitively intact, R8's weight was 156 pounds (lb), and R8 had no significant weight loss within the last six months. The last documented nutritional assessment in R8's medical record is dated as 3/2/24 and there is no documentation that R8's significant weight loss in September was evaluated by a dietitian. R8's ongoing weight log documents R8's weight as follows: 4/4/24 150.4 lbs, 7/1/24 156.4 lbs, 8/2/24 156 lbs, 9/2/24 146 lbs (6.41% loss in one month), and 10/30/24 143 lbs (8.3% loss in three months). There were no documented weights in R8's medical record after 9/2/24 until 10/30/24. R8's Care Plan dated 5/26/23 documents R8 has a nutritional problem related to abnormal weight loss and interventions include to provide supplements as ordered, dietitian to evaluate and make dietary changes as needed. This care plan does not document any nutritional interventions were developed/implemented after 5/26/23 to address R8's significant weight loss. R8's active October 2024 physician's orders documents R8's diet as Regular/Mechanical Soft. There are no documented orders for nutritional supplements. R8's Wound Care Telemedicine Follow Up Evaluation dated 10/25/24 documents R8 has stage three pressure ulcers to the right buttock and left hip. On 10/27/24 at 10:23 AM R8 was in the dining room eating. R8's meal consisted of waffles, banana, and sausage, and did not include any nutritional supplements. On 10/29/24 at 12:34 PM V19 Registered Dietitian stated R8 was due for an annual nutritional evaluation in June 2024, but one was not done because the electronic software program did not trigger for one to be done with R8's annual MDS. V19 stated R8's last nutritional assessment was completed in March 2024. V19 stated no one had requested to evaluate R8's nutritional status and V19 was unaware that R8 had developed pressure ulcers. V19 stated residents with wounds should be evaluated by the dietitian monthly. If V19 had evaluated R8, V19 would have recommended Zinc, Vitamin C, a multivitamin, liquid protein. V19 stated V19 possibly would have recommended a nutritional supplement if R8 had lost weight, but R8 does not have a documented weight for October. On 10/29/24 at 2:00 PM V2 Director of Nursing stated weights are recorded under the weight section of the resident's electronic medical record. R8's weight was requested to be obtained at this time. On 10/30/24 at 11:02 AM V10 Restorative Nurse/Registered Nurse stated R8's weight today was 143 lbs. 2.) R44's weight flow sheet documents on 05/12/2024, (R44) weighed 125.8 lbs. On 10/04/2024, R44 weighed 101.2 pounds which is a 19.55 % Loss. R44's Wound Care Telemedicine initial evaluation dated 10/18/24 by V7, Wound Physician documents R44 developed a facility acquired Stage III Pressure Ulcer of greater than 10 days duration on the coccyx. 10/29/24 12:39 PM V19 Registered Dietitian stated The facility does not reach out to me when a resident has a wound or a significant weight loss. Yes I should be notified of a significant weight loss and/or a wound and I should evaluate these residents. V19 verified V19 has not evaluated R44. 3.) R52's weight flow sheet documents on 09/03/2024, R52 weighed 131.2 lbs. on 10/15/2024, R52 weighed 123.6 pounds which is a 5.79 % loss. R52's Treatment Administration Record (TAR) for October 2024 documents a new treatment dated 10/26/24 for Clean area to left buttock with normal saline. Apply calcium alginate to wound bed & cover with gauze foam daily every day shift for wound care. On 10/29/24 at 10:00 AM V12 Licensed Practical Nurse (wound Nurse) stated (R52) developed a new facility acquired Stage II pressure ulcer on 10/25/24. We are treating it. 10/29/24 12:39 PM V19 Registered Dietitian stated The facility does not reach out to me when a resident has a wound or a significant weight loss. Yes I should be notified of a significant weight loss and/or a wound and I should evaluate these residents. V19 verified V19 has not evaluated R52.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct pressure ulcer risk assessments (R1, R5, R6), failed to obtain treatment orders for identified pressure ulcers (R5, R6), failed to complete pressure ulcer monitoring (R5, R6), and failed to complete pressure ulcer treatments according to physician orders (R5, R6). These failures affect three residents (R1, R5, and R6) out of three reviewed for pressure ulcer services on the sample of six. These failures resulted in R5 developing a worsening stage 3 pressure ulcer. Findings include: The facility's policy Braden Pressure Risk Assessment Tool dated [DATE], documents each resident should be assessed for risk of developing pressure ulcers on admission, weekly for the first month, at least quarterly, and with any significant change in condition, utilizing the Braden scale assessment form. The facility policy Measurement of Alterations in Skin Integrity dated [DATE], documents all skin alterations, wounds, and ulcers will be measured weekly and the results documented in the clinical record. This policy describes the stages of pressure ulcers, instructs staff to assign a stage to the ulcer, document a description of the ulcer, measure the ulcer, measure or describe the depth of the ulcer, and to describe any drainage or odors. 1. R5's Assessments dated [DATE] document this was the most recent date located in R5's medical record for facility staff assessing R5's risk for developing pressure ulcers utilizing the Braden scale pressure ulcer risk assessment tool. On [DATE] at 1:15 PM, V1, Administrator, stated, I know we have a more recent Bradens than over a year ago, I completed a whole house sweep of every resident for a Braden back in April, but even that still puts us over a quarter behind. V1, Administrator, provided a more recent Braden assessment dated [DATE] which rated R5 as at risk. R5's Care Plan documents a focus area of R5's risk for impaired skin integrity with a nursing intervention listed as Braden scale weekly x 4 weeks then quarterly, initiated [DATE]. R5's Nurses Note dated [DATE] documents a notation of an open pressure ulcer located on R5's left buttock measuring 2 centimeters (cm) by 1.5 cm. R5's Nurses Note dated [DATE] documents R5's dressing change for the left buttock was unable to be completed because R5 was sitting in a chair. R5's Nurses Note dated [DATE] documents R5's dressing change for the left buttock was completed by the wound nurse. There was no documentation of measurements nor a description of this ulcer. R5's Nurses Note dated [DATE] documents R5's dressing change for R5's wounds was completed by the hospice nurse and also documented an open ulcer located on R5's coccyx measuring 2 cm by 1.5 cm. There was no mention of the left buttock ulcer, and no description of either ulcer. R5's Nurses Note dated [DATE] documents completion of wound rounds with the wound physician, the physician ordered to continue the current treatments, and that R5 had no open areas. R5's Nurses Note dated [DATE] documents R5 had open wounds with dressings in place. There was no documented location, measurements, nor descriptions of the open wounds. R5's Nurses Note dated [DATE] documents the presence R5's left buttock ulcer. There was no documented measurements nor description of this ulcer, nor any mention of R5's coccyx open ulcer. R5's Treatment Administration Record dated for [DATE] documents a treatment order for R5's coccyx ulcer was not obtained or implemented until [DATE]. This record documents R5's treatment for the coccyx ulcer was not completed according to the physician orders on [DATE] and [DATE] on day shift. This same record documents R5's coccyx treatment was discontinued and changed to the evening shift on [DATE]. This same record documents R5's left buttock treatment order had been continuously in R5's treatment record from [DATE] through the current date ([DATE]), disputing the documentation on [DATE] that R5 had no open areas during the wound rounds. This record documents R5's treatment for the left buttock was not completed according to physician orders on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. This same record documents the treatment for R5's left buttock was likewise discontinued [DATE] and changed to the evening shift. R5's Treatment Administration Record dated for [DATE] documents R5's treatment for the open ulcer on R5's coccyx was not completed on [DATE]. This record documents the treatment order for R5's coccyx was revised [DATE] and implemented to begin [DATE]. On [DATE] at 1:15 PM, V1. Administrator, stated, We know we have some things to work on and improve. We have not been consistent in doing our weekly measurements. Part of the issue is we had a wound company who stopped serving our facility back in February (2024), then the new practitioner is only providing us their service when they can squeeze us into their schedule, and they aren't actually coming onsite, they are doing their visits by telehealth (virtual visits over the computer). V1 continued, We did designate one of our nurses as the wound nurse, but her training has been delayed because we had needs for her to work the floor (in direct care). On [DATE] at 1:15 PM, V2, Director of Nursing, stated, We also have had to use agency nurses which do not necessarily know the residents well and are not diligent about signing treatments in the record. We also have cross over of shifts like some nurses might work 12 hours shifts and some work 8 hour shifts, so there is some confusion about which nurse is going to do the treatments when they are set up as day shift or evening shift. On [DATE] at 2:35 PM, facilitated by V10, Licensed Practical Nurse, and V2, Director of Nursing, R5's coccyx ulcer was observed to be approximately (visually estimated but confirmed by V10 and V2) 3.5 cm long by 0.5 cm wide and apparently stage 3 with full thickness skin loss and subcutaneous (fat) tissue exposed. This open ulcer was surrounded by an area of non-blanchable redness (stage 1 with tissue damage already occurred) approximately (again confirmed with V2 and V10) 7 cm long by 6 cm wide. On [DATE] at 2:35 PM, V10 stated, When this ulcer first started it was open stage 3 like this, it remained stable for a few weeks, then it worsened and has been like that for the past several weeks. On [DATE] at 3:25 PM, V1, Administrator, stated, The treatment orders have to be obtained faster than that (from [DATE] until [DATE]). I would expect a nurse to at least put a dry gauze dressing in place when they first notice an open area, then turn it over to inform the physician to obtain a more targeted treatment. 2. R6's Assessments dated [DATE] document this was the most recent date located in R6's medical record for facility staff assessing R6's risk for developing pressure ulcers utilizing the Braden scale pressure ulcer risk assessment tool. On [DATE] at 1:15 pm, V1, Administrator, provided a more recent Braden assessment dated [DATE] which rated R6 as very limited risk. R6's Care Plan documents a focus area that R6 is at risk for altered skin integrity and potential for pressure ulcers with nursing interventions including Braden scale quarterly, implemented [DATE]. R6's Nurses Notes dated [DATE] document R6 developed an open pressure ulcer on the left shoulder which measured 1 cm by 1 cm. There was no depth measurement, nor a description of this open area. This same Nurses Note documents R6 also developed a second open pressure ulcer on the left hip measuring 1 cm by 0.5 cm. There was likewise no depth measurement or description of this second open ulcer. R6's Nurses Notes dated [DATE] document a second notation of R6's two open areas. This note documented the open ulcer on R6's left shoulder measured 2 cm by 1.4 cm, indicating this area had grown in size since [DATE]. There was no depth measurement nor description for R6's open ulcer on the shoulder. This note documented the open ulcer on R6's left hip measured 0.5 cm by 0.5 cm with no documented depth measurement nor description. There were no additional measurements nor descriptions between [DATE] and [DATE]. R6's historical Physician Order Sheet and Treatment Administration Record for [DATE] document there was not a treatment order obtained from R6's physician to treat the two open ulcers until [DATE], at which time the orders for treatment indicated R6's open ulcers were on the right shoulder and right hip. On [DATE] at 2:35 PM, V2, Director of Nursing, stated, The ulcers are actually on (R6's) right hip and right shoulder. (Staff) must have been looking at (R6) and documented what side the ulcers were related to their own left not the residents left. R6's Nurses Notes dated [DATE] documented the presence of R6's two open ulcers but no measurements or description. There were no additional measurements or descriptions between the note on [DATE] and [DATE]. R6's Treatment Administration Record dated for [DATE] documents the treatment for the pressure ulcer on R6's right shoulder was not completed according to the physician orders on [DATE] for the day shift. This same treatment order was documented as discontinued on [DATE] and changed to the evening shift. This same treatment record documents R6's treatment for the right hip was not completed on [DATE] and [DATE] for the day shift. This right hip treatment was likewise discontinued [DATE] and changed to the evening shift. On [DATE] at 2:35 PM, facilitated by V10, Licensed Practical Nurse/ Wound Care Nurse, and V2, Director of Nursing, R6's pressure ulcer of the right shoulder was observed to be a stage 2 (partial skin thickness) with surrounding healing scar tissue, and likewise the right hip pressure ulcer on R6 was a stage 2 with surrounding healing scar tissue. On [DATE] at 1:35 PM, V10 stated, Those are definitely stage 2, partial skin layers. They used to be larger but they have been healing. They have always been stage 2. On [DATE] at 3:25 PM, V1, Administrator, stated, The treatment orders have to be obtained faster than that (from [DATE] until [DATE]). I would expect a nurse to at least put a dry gauze dressing in place when they first notice an open area, then turn it over to inform the physician to obtain a more targeted treatment. 3. R1's Minimum Data Set List and Census Details document R1 was discharged deceased from the facility [DATE]. R1's Assessments dated [DATE] documents this was the most recent pressure ulcer risk assessments utilizing the Braden scale pressure ulcer risk assessment tool conducted by facility staff located in R1's medical record. On [DATE] at 1:15 PM, V1, Administrator, provided a more recent Braden assessment dated [DATE], rating R1 as high risk for pressure ulcers. R1's Nurses Note dated [DATE] documents a notation of a sore located on R1's left ankle with a measurement of 7 cm long by 6 cm wide, along with an area of redness on R1's right heel. A subsequent nurses note on this same date documented the presence of redness on R1's gluteal area (buttock) and coccyx. On [DATE] at 9:55 AM, V1, Administrator (former direct care registered nurse at the facility), stated, I did see (R1's) ulcer on the ankle. I did see that the nurse (V5, Registered Nurse) documented the area on (R1's) ankle was 7 cm by 6 cm, but I think he was measuring the entire area, but the hole in the skin was only about this big. V1 held up his fingers to indicate approximately 0.75 cm diameter. V1 further stated, I would stage that ulcer at stage 2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transfer residents to the hospital timely for evaluation, notify the physician of a resident's change in condition, and provide medical care timely after falls for two of four residents (R1 and R4) reviewed for falls on the sample list of four residents. Failing to transfer R1 to the hospital timely and notify the physician of neurological changes after R1 fell resulted in a delay in treatment and R1 experiencing pain and vomiting. Findings include: 1.) R1's undated Medical Diagnosis List documents R1's medical diagnoses as Atrial Fibrillation, Weakness, Need for Assistance with Personal Care, Dementia, History of Falling, Repeated Falls, Convulsions, Inflammatory Spondylopathy Lumbar Region, Transischemic Attack (TIA) and Cerebral Infarction. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as requiring supervision for transfers, bathing, mobility, eating, personal hygiene and walking. R1's Nurse Progress Note dated 5/5/24 at 6:00 AM documents (R1) was ambulating to the bathroom with walker with (V8) CNA when (R1) stopped responding to (V8) CNA and fell backwards. (V8) CNA was unable to catch (R1). (R1) noted to be in a post-ictal like state. (V8) CNA reported that resident did hit head. (R1) began to become more alert and endorsed pain in her left arm which is currently in a sling due to a Humerus fracture. (R1) assisted up via staff (V8, V12) and placed in bed. R1's Nurse Progress Note dated 5/5/24 at 10:44 AM documents (R1) sent out to emergency room. (V22) RN told this nurse that (R1) had a fall last night and hit her head. (R1) unable to put weight on Left Leg and cries out in pain. (V8) CNA told this writer when (R1) fell (V8) CNA noticed (R1's) eyes rolling to the back of head and gagging. (R1) has altered mental status, decreased level of consciousness (LOC) and unable to keep eyes open and respond. R1's Hospital Record dated 5/5/24-5/8/24 documents R1 transferred to this hospital's trauma unit via air transfer from community hospital due to a mechanism of fall. The record documents (R1) is a [AGE] year old female with multiple prior falls who fell at facility again today (5/5) and subsequently developed progressive altered mental status (AMS) and is incomprehensible moaning at this time. This same report documents R1 showed tenderness to her Posterior Scalp and her pupils were pinpoint bilaterally. This same report documents R1's Computerized Tomography (CT) results documents R1's Acute Sub Arachnoid Hematoma along the bilateral frontal lobes, five millimeter (mm) Left Convexity Acute Subdural Hematoma, three mm Rightward midline shift, Right Parietal Lobe chronic infarction and Nondepressed Left Occipital Bone Fracture. This same report documents This is a significant brain injury and is not survivable in her condition. [AGE] year old woman status post fall now with multifocal Subarachnoid and Holohemispheric Left Subdural Hematoma. In the setting of age, significant prior stroke, and Dementia-this is a non-survivable injury. R1's Final Incident Report to State Agency dated 5/5/24 documents R1 fell on 5/5/24 at 5:10 AM while being transferred by staff to bathroom. (V8) CNA was ambulating with (R1) to the bathroom when (R1) stopped responding to V8 CNA, stared forward and did not blink. R1 fell backwards before (V8) could catch her. (R1) appeared to be in a post-ictal state, mentation slowly improved and staff assisted (R1) up and into bed. (R1) given pain medication. R1 obtained a 'Hemorrhage, Fractured Occipital Bone and Left Hip Fracture'. R1's Physician Progress Note dated 5/9/24 documents (R1) readmitted on [DATE] post fall at facility, hit her head and has skull fracture with Subdural bleed. Is pending Hospice admission for comfort cares. On 5/14/24 at 10:48 AM V12 Certified Nurse Aide (CNA) stated V12 came on duty the early morning of 5/5/24 and heard 'commotion' from R1's room. V12 stated I went to (R1's) room and saw (R1) laying on the floor with her feet towards the bathroom door and her head was towards the room door. (R1) was laying on her back. (R1's) eyes were going back and forth real fast. (V8) CNA told me that (V8) was taking (R1) to the bathroom and (R1) fell straight back and hit her head hard two or three times. (R1) did not have a gait belt on and I didn't see one in the room. (V2) Director of Nurses (DON) told us (V8, V12) to get R1 up and lay her on (R1's) bed so we did. (R1) wasn't walking very well. (R1) was still pretty out of it. (R1) was vomiting and I was afraid she was going to choke on her own vomit so I got her laid on her side on the bed. (R1) was coughing and choking. It was so scary. We (V8, V12) told (V2) about (R1) vomiting and gagging. (V2) had stepped out of the room to get the IPAD to call the telehealth doctor. On 5/14/24 at 1:05 PM V2 Director of Nurses (DON) stated V8 Certified Nurse Aide (CNA) was walking R1 to the bathroom. V2 stated R1 quit responding when V8 opened the bathroom door. V2 stated V2 was told R1 had a blank stare and then fell backwards. V2 DON stated V2 was at the nurses station when R1 fell. V2 stated When I saw (R1), she was laying on her back on the floor with her head towards the door and her feet towards the bathroom. (R1) was somewhat responsive but not as much as usual. (R1) was complaining of pain in her Left Arm. They (V8, V12) got (R1) back to bed. I gave (R1) a pain pill which she took orally. (R1) seemed very drowsy but was able to answer some basic questions. The telehealth doctor was able to see (R1) laying in bed with her eyes closed and gave orders to keep monitoring her and return the call if (R1's) mentation changes. On 5/14/24 at 2:40 PM V36 (R1) Power of Attorney (POA) for Healthcare stated As soon as (R1) fell, they (facility) should have just called for the ambulance. We (family) had not planned on (R1) going on hospice. Before these last two falls, (R1) was up walking all over, eating well, talking with staff. Even with (R1's) Dementia she was living a good life. After the fall on 5/5/24 the hospital told us that she would not survive because of that fall. It is really sad. On 5/15/24 at 10:35 AM V23 Certified Nurse Aide (CNA) stated V23 worked 6:00 AM-2:00 PM on 5/5/24. V23 stated V23 was told in verbal report that R1 had fallen earlier that morning. V23 stated I was told (R1) fell, hit her head hard and her eyes were rolling back in her head and she was gagging a bit. I was told that (V8) CNA was the only person with (R1) and didn't have a gait belt on her. I was told to keep an eye on her. I helped (V17) take her to the toilet at 9:00 AM. (V22) Registered Nurse (RN) told us (V17, V23) to get (R1) out of bed, take her to the bathroom, get her dressed and bring her out to the nurses medication cart so (V22) RN could see her better. (R1) was not right. (R1) was moaning and crying out in pain. That was the first time I saw (R1) was at 9:00 AM. We (V17, V23) did what (V22) asked in getting (R1) up. (R1) was not right. I have taken care of (R1) plenty of times and she was not right. On 5/15/24 at 10:50 AM V22 Registered Nurse (RN) stated V22 was R1's day shift nurse on 5/5/24. V22 RN stated I came in and got in report from (V2) Director of Nurses (DON) that (R1) had fallen, hit her head and was not sent in to the emergency room but resting in her room. V22 RN stated V22 was aware R1 was in the beginning of her Neurological Assessments and should have assessed R1 more frequently. V22 RN stated V22 assessed R1's Neurological status at 6:55 AM and again at 7:55 AM. V22 stated When I assessed (R1) at 6:55 AM she was complaining of pain in her hip, leg and arm so I gave her a pain pill. (R1) was moaning and crying out. (R1) was not responding as per her normal. I should have sent (R1) to the emergency room as soon as I saw her but didn't because I was too busy. (R1) should have had better care. I feel awful. V22 RN stated V20 Licensed Practical Nurse (LPN) came on duty at 10:00 AM. V22 RN stated she waited until V20 LPN came on duty to have V20 send R1 to the emergency room. V22 RN stated (V22) told them (V17, V23) Certified Nurse Aides (CNA) to get (R1) up out of bed, assist her to the toilet and then get her dressed and bring her to me. I can't assess a resident in these rooms. There is not enough light. When they (V17, V23) brought her to me (R1) couldn't stand. I asked (V17, V23) to stand (R1) up out of her wheelchair. (R1) was not responding very well. (R1) was screaming in pain as I assessed her. This was about 9:00 AM. (V20) LPN came in at 10:00 AM and got (R1) sent out for me. On 5/15/24 at 11:32 AM V17 Certified Nurse Aide (CNA) stated V17 was assigned as R1's CNA on 5/5/24. V17 stated I checked on (R1) and she looked like she was sleeping in her bed. (R1) was moaning in pain. This was about 7:00 AM. I let the nurse (V22) know. I didn't see any real injuries for (R1). (V22) Registered Nurse (RN) told us (V17, V23) to get (R1) up, dressed, toileted and bring (R1) to (V22) out in the hallway by her medication cart. (V23) and I used a gait belt and walked (R1) to the bathroom. (R1) was not walking right and she was crying out in pain. Even when we (V17, V23) got her up, she was leaning to the side while we were trying to get her to sit on the side of the bed. This was 9:00 AM. We (V17, V23) both told (V22) RN about (R1's) pain and change in her overall condition. On 5/16/24 at 11:35 AM V20 Licensed Practical Nurse (LPN) stated I came into work on 5/5/24 at 10:00 AM. As soon as I got report from (V22) RN about (R1), I briefly assessed (R1) and knew that she needed to be sent to the emergency room. I didn't even do the full neuros (Neurological Assessment) because it was obvious something was really wrong. I am not sure why (R1) was not sent out to begin with right after she fell but I wasn't going to let (R1) suffer any longer. On 5/15/24 at 3:40 PM V14 Medical Director stated R1 fell on 5/5 at the facility during a witnessed fall. V14 confirmed R1 was not transferred safely which contributed to R1's fall. V14 Medical Director stated anytime a resident has a witnessed fall and they 'hit hard' such as R1 did on 5/5, that resident should be automatically sent to the emergency room. V14 stated You don't need a Physician order to send one of the residents to the emergency room for evaluation. That is left to the nurse's critical thinking skills. V14 stated the facility should have sent R1 to the emergency room immediately after the fall. V14 stated moving R1 could have worsened her injuries. V14 stated R1 sustained several major injuries which could affect her neurological status. On 5/15/24 at 3:00 PM V1 Administrator stated the facility should have called 911 emergency services for R1 at the time of her fall on 5/5/24. V1 Administrator stated I am not a nurse but would definitely consider (R1's) fall on 5/5/24 an emergent situation. Telehealth is a service that is available to our nursing staff for after hours Physician notification but it is not meant for emergency situations as what happened with (R1). 2.) R4's undated Medical Diagnosis List documents R4's medical diagnoses as Diabetes Mellitus Type II, Chronic Congestive Heart Failure, Kidney Failure, Persistent Atrial Fibrillation, Muscle Weakness, Abnormalities of Gait and Mobility, Dementia, Unsteady on Feet and History of Falling. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires maximum assistance for toileting, bathing, dressing, personal hygiene and transfers. R4's Physician Order Sheet (POS) dated May 2024 documents a physician order starting 4/5/24 for Apixaban (anticoagulant) 2.5 milligrams (mg) daily. R4's Fall Evaluation dated 5/5/24 documents R4 obtained a Laceration below R4's Left Eyebrow measuring 1.2 centimeters (cm) long by 0.5 cm wide by no measurable depth and a laceration to R4's Left Eyebrow measuring 1.5 cm by 0.8 cm by no measurable depth. R4's undated Fall Investigation documents R4 had an unwitnessed fall on 5/5/24 at 1:45 AM. This same report documents R4 observed in R4's bed approximately one hour prior to fall and was last toileted at 10:00 PM on 5/4/24. This same report documents R4 requires the assistance of one person and a walker, is severely cognitively impaired, and was found lying on the floor in the doorway of R4's room face down. The report documents R4 had one shoe on and the other half on/half off and R4 obtained two lacerations to his Left Eye and the wound was cleansed and steri strip applied. R4's Medication Administration Record (MAR) dated May 2024 documents R4 rated his pain at a three out of ten and was administered Acetaminophen 650 milligrams (mg) at 6:00 AM on 5/5/24. R4's Physician Progress Note dated 5/5/24 (no time documented) documents physician orders for Left Hip, Unilateral with Pelvis when performed, 2-3 views/Facial Bones, less than 3 views/Left Radiologic examination, femur; minimum 2 views, completed 5/6/24. R4's Nurse Progress Note dated 5/5/24 at 9:00 PM documents R4 was sent to the emergency room due to (R1) screaming 'somebody help me' due to Inguinal pain. R4's Nurse Progress Note dated 5/6/24 at 10:47 AM documents (R4's) order for Hip/Pelvis and Femur of Left side made via portable X-Ray. On 5/15/24 at 11:45 AM R4 was laying in his bed. R4 stated I don't remember exactly what happened but I know I fell. My eye (rubbing his Left eye) still hurts. I have problems holding my urine. If I have to go to the bathroom then I need to go as soon as I can get there. On 5/15/24 at 2:30 PM V2 Director of Nurses (DON) stated the night (5/5/24) R4 had an unwitnessed fall R4 was trying to find someone to help him get to the bathroom. V2 DON stated (R4) got up from bed and walked to the doorway of his room where he was found. (R4) had a goose egg and laceration on his Left eyebrow/forehead area. I provided first aid, the staff got him back up and helped him to the bathroom. On 5/17/24 at 1:00 PM V1 Administrator stated any resident on an anticoagulant who has fallen and obtained a head injury should be sent to the emergency room. V1 stated I am not sure why we (facility) waited to get the X-Rays done but we should have called for them that morning (R4) fell. (R4) could have had an internal injury that we couldn't see from the outside and we would never have known. The facility policy titled 'Falls and Fall Risk, Managing' revised August 2008 documents the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. Staff will identify and implement relevant interventions (e.g. hip padding or treatment of Osteoporosis, as applicable) to try to minimize serious consequences of falling. The staff, with the Physicians guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or Subdural Hematoma have been ruled out or resolved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain ordered kidney function laboratory work and failed to complete neurological exams following a fall with a head injury for one of three residents (R3) reviewed for falls. These failures resulted in R3 being admitted to the hospital for Acute Kidney Injury, Dehydration and Altered Mental Status. Findings include: The facility's Falls-Clinical Protocol policy with a revised date of August 2008 documents, Assessment and Recognition 2. In addition, the nurse shall assess and document/report the following: a. vital signs b. Recent injury, especially fracture or head injury c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. (etcetera) d. Change in cognition or level of consciousness e. Neurological status. This policy also documents, Monitoring and Follow-Up. 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. The facility's undated Neurological Assessments Procedures provided by V2 Director of Nursing on 1/30/24 at 11:30 AM documents, Neurological assessments should be performed as follows for a 72 hour period, unless otherwise ordered by the attending physician. Every 15 minutes x (times) 4, Every 1 hour x 4, Every 2 hours x 8, Every 4 hours until the 72 hour time period is complete. Notify the physician of any significant change in neurological status immediately. 1.) R3's hospital History and Physical dated 1/3/24 documents R3 was admitted to the hospital for a fall with renal and splenic hematomas. This History and Physical documents laboratory levels for the BUN (Blood Urea Nitrogen) (test for kidney function) of 23 mg/dl (milligrams/deciliter) (5-25 normal range) and Creatinine (test for kidney function) of 1.45 mg/dl (0.5-1.4 normal range). R3's hospital after visit summary dated 1/12/24 documents to repeat the BMP (Basic Metabolic Panel) (includes BUN and Creatinine) within 5-7 days of discharge (discharge of 1/12/24). R3's Physician's Order documents an order for a BMP 5-7 days post hospital discharge with a start date of 1/17/24 and a stop date of 1/18/24. R3's medical record does not contain a BMP after admission on [DATE]. R3's Nurse's Note dated 1/22/24 at 12:05 PM by V4 Advance Practice Registered Nurse documents that V4 called R3's Power of Attorney (POA) and reported R3's increased altered mental status, poor oral intake and headache. This note documents POA stated that R3 was not R3's self yesterday and agreed to send R3 to the Emergency Room. EMS (Emergency Medical Services) called and R3 sent to the hospital. R3 Nurse's Note dated 1/22/24 at 9:07 PM by V10 Registered Nurse documents V10 spoke to the hospital and R3 was admitted with diagnoses including Acute Kidney Injury, Dehydration and Altered Mental Status. On 1/30/24 at 1:34 PM, V1 Administrator confirmed R3's BMP did not get completed and V1 does not know why. On 1/30/24 at 2:30 PM, V4 Advance Practice Registered Nurse stated if the facility would have completed R3's BMP on 1/17/24 and the values were elevated V4 would have started IV (Intravenous) fluids and that may have kept R3 from having to go to the hospital. R3's hospital laboratory results dated [DATE] document a BUN of 46 (abnormal value) and a Creatinine of 1.5 (abnormal value). 2.) R3's Nurse's Notes dated 1/18/24 at 7:34 PM by V10 Registered Nurse documents at 7:15 PM a CNA (Certified Nursing Assistant) reported to V10 that R3 was found on the floor in front of the wheelchair laying on R3's left side. This note documents that neurological checks were initiated. The Neurological Assessment Flow Sheet documents that neurological checks were initiated at 7:15 PM every 15 minutes x 4, then every hour x 4, then every two hours x 8 with the last one being documented at 2:00 PM on 1/19/24. The next neurological check would have been at 6:00 PM but R3 had another fall. R3's Nurse's Note dated 1/19/24 at 6:00 PM by V13 Licensed Practical Nurse documents they heard a loud noise and the CNA ran to R3's room and R3 had fallen and hit R3's head. R3 had a laceration to the left side of R3's head and was bleeding. EMS (Emergency Medical Service) was called and they took R3 to the Emergency Room. R3's Nurse's Note dated 1/19/24 at 8:45 PM by V13 documents V13 spoke to the hospital nurse and they stated that R3 had 5 staples placed to the left side of R3's head. R3's Nurse's Note dated 1/19/24 at 11:00 PM by V14 Registered Nurse documents R3 returned from the hospital at 10:15 PM and neurological checks were within normal limits. R3's Neurological Assessment Flow Sheet documents the neurological checks (neuros) were restarted at 10:30 PM and then another at 1:00 AM on 1/20/24 then one more at 5:00 AM. R3's Nurses Notes document that R3 returned to the facility on 1/19/24 at 10:15 PM which was 4 1/4 hours after the second fall. R3 should have resumed the neuros with one remaining one hour check left and then eight remaining two hours checks and then the four hour checks to get to the 72 hours. R3's Neurological Assessment Flow Sheet only documents three checks being completed after R3 returned from the hospital and only one of those checks were completed at the appropriate time. On 1/30/24 at 11:08 AM, V4 Advance Practice Registered Nurse stated that V4 was under the understanding that the nurses were completing the neurological exams on R3 when R3 came back from the fall on 1/19/24. V4 stated that V4 expects them to pick up the neurological exams when R3 returned at the time frame R3 returned at. V4 stated that V4 examined R3 on 1/22/24 because nursing staff requested due to a change in condition and V4 sent R3 to the hospital for altered mental status. On 1/30/24 at 11:41 AM, V8 Licensed Practical Nurse stated that on 1/21/24 R3 wasn't chewing food well but R3 did not have any bottom teeth so V8 downgraded R3's diet to mechanical soft. V8 stated that R3 would get tired after receiving the Parkinson's Disease medication and that was normal for R3. On 1/30/24 at 11:53 AM, V10 Registered Nurse stated that on 1/22/24 V10 gave R3 the morning medications and R3 took them fine but after breakfast V10 noticed a decline in R3's condition and notified the Nurse Practitioner and V4 Advance Practice Registered Nurse examined R3 and sent R3 to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement fall prevention interventions to prevent falls for three of three residents (R2, R3, R4) reviewed for falls in the sample list of five. These failures resulted in R2 and R3 falling and suffering head lacerations that required staples at the emergency room. Findings include: The facility's Falls - Clinical Protocol policy with a revised date of August 2008 documents, As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The facility's Falls and Fall Risk, Managing policy with a revised date of August 2008 documents, 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. The facility's undated Gait Belt Policy & Procedure documents, It is the policy of this facility that gait belts are utilized on all residents requiring physical assistance with transfer unless contraindicated. The gait belt will be utilized for any resident that has been assessed to need a mechanical lift or stand by assist for safe transfer ability. 1.) R2's Order Summary Report documents diagnoses including Radiculopathy Lumbar Region, Other Malaise, Low Back Pain, Weakness, Morbid Obesity, Other Intervertebral Disc Degeneration Lumbar Region, Discitis Lumbar Region, Muscle Weakness, Unsteadiness on Feet and Difficulty in Walking. This Order Summary Report documents an order for Apixaban (anticoagulant) 5 mg (milligrams) twice a day with a start date of 10/4/23. R2's Care Plan dated 10/5/23 documents R2 is at risk for falls related to gait/balance problems, unaware of safety needs, Pain, Incontinence, Obesity, Depression, limited/decreased mobility, Osteoarthritis and Restless Leg Syndrome with an intervention to maintain a clear pathway in the room and free of obstacles. This Care Plan does not document how R2's transfers or ambulates. R2's Minimum Data Set (MDS) dated [DATE] documents R2 requires partial/moderate assistance for moving from a sitting position to a standing position, transferring from a chair to the bed or wheelchair and to walk 10 feet. Partial/moderate assistance is documented as the helper lifts, holds or supports the trunk or limbs. This MDS documents R2 has moderately impaired cognition with a BIMS (Brief Interview for Mental Status) of 11/15. The facility's Detailed Incident Summary dated 1/16/24 completed by V2 Director of Nursing documents on 1/10/24 at 1:00 AM, R2 turned on the call light for assistance to ambulate to the bathroom. V3 Certified Nursing Assistant assisted R2 with the walker and began ambulating to the bathroom. R2 requested V3 move a trash can. V3 bent down, picked up the trash can and turned to set it down when V3 heard R2's walker rattle. V3 was unable to catch R2 before R2 fell. The nurse on duty assessed R2 and R2 had a laceration on the back of the head. R2 was sent to the emergency room. R2's emergency room note dated 1/10/24 documents Patient Discharge Instruction which documents 6 staples, discharge diagnoses of a Fall - Primary and Laceration of Head - Primary. R2's Computed Tomography (CT) scans dated 1/10/24 document no acute fractures. R2's CT of the head dated 1/10/24 at 1:53 AM documents Clinical History/Indication for exam as pain - [AGE] year old female in emergency room (ER) after a fall hitting the back of (R2's) head, laceration to the back of the head. This ER report documents R2 received Fentanyl (narcotic pain reliever) IV (Intravenous) push of 50 mcg (micrograms) at 2:30 AM, Fentanyl 25 mcg IV push at 2:45 AM and Fentanyl 25 mcg IV push at 4:10 AM. This ER report documents wound care type - laceration to posterior head measuring 6 cm (centimeters) long by 0.5 cm wide by 0.25 cm deep. This report documents observed behaviors of R2 as grimacing, guarding, moaning and restraint to movement. On 1/29/24 at 1:04 PM, V3 Certified Nursing Assistant (CNA) stated that on 1/10/24 V3 answered R2's call light. V3 stated R2 needed to go to the bathroom so V3 moved the bedside table and assisted R2 to stand with the walker in front of R2. V3 stated R2 requested V3 move a trash can out of the way and V3 stated V3 bent over to move it and as V3 turned around R2 was falling to the floor. V3 stated that V3 got assistance from the nurse and sat R2 up and saw blood and the nurse called EMS (Emergency Medical Services) and they transferred R2 to the hospital. V3 confirmed V3 did not use a gait belt on R2 during the transfer and did not keep hands on R2 the entire time. On 1/29/24 at 1:29 PM, V2 Director of Nursing stated that V3 did not use a gait belt when transferring R2 but should have used a gait belt. On 1/30/24 at 8:55 AM, R2 stated that R2 was getting out of bed and the next thing R2 knew was R2 fell and hit the bottom part of the bed frame with the back of R2's head. R2 stated that R2 has right sided neck pain now after the fall. On 1/30/24 at 9:29 AM, V6 Physical Therapy Assistant/Director of Rehab stated that at the time of the fall on 1/10/24 that R2 would have required the assistance of one staff member. V6 confirmed that assistance should have been with a gait belt and hands on R2 for transfers. On 1/30/24 at 10:33 AM, V7 CNA/RNA (Restorative Nursing Assistant) and V5 CNA applied a gait belt to R2 while R2 was in the wheelchair and they both assisted R2 with hands on the gait belt to shuffle R2's feet over to the recliner and R2 sat down. V7 and V5 removed the gait belt and gave R2 the call light cord. On 1/30/24 at 11:08 AM, V4 Advanced Practice Registered Nurse confirmed that R2's fall on 1/10/24 caused the laceration to the back of R2's head and required an emergency room visit for 6 staples to close the wound. 2.) R3's Care Plan dated 1/15/24 documents R3 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Sleep Disorder, Orthostatic Hypotension, Weakness, Difficulty in Walking, History of Falling, Unspecified Dementia, Other Spondylosis with Radiculopathy Thoracic Region and Low Back Pain. This Care Plan documents R3 is at risk for falls related to gait/balance problems, Pain, Restless Leg Syndrome, Type 2 Diabetes, History of Falls, Unsteady Gait, Low Back Pain and Parkinson's disease dated 1/15/2024 with an intervention of a bed alarm and a chair alarm dated 1/18/24 and ensure that R3 is wearing appropriate footwear when transferring, ambulating or mobilizing in the wheelchair dated 1/15/2024. R3's MDS dated [DATE] documents R3 requires partial/moderate assistance for moving from a sitting position to a standing position, transferring from a chair to the bed or wheelchair and to walk 10 feet. Partial/moderate assistance is documented as the helper lifts, holds or supports the trunk or limbs. This MDS documents R3 has severe cognitive impairment. R3's Incident Investigation for 1/19/24 at 6:00 PM documents R3 had a prior fall on 1/18/24. This report documents a Summary of events/situation as the CNA entered R3's room and positioned R3 on the edge of the bed to eat R3's dinner with the tray in front of R3 and feet on the floor. This CNA exited the room. Approximately 15 to 20 minutes later another CNA heard a crash and responded to R3's room. R3 was bleeding from the left side of R3's head. Pressure was applied and EMS was called. This report documents that in the emergency room R3 had a laceration to the left side of the head closed with 5 staples. A CT scan was completed at that time and was clear. R3 returned to the facility. This Investigation includes a statement from V12 CNA which documents when V12 last saw R3 sitting on the edge of the bed that R3 had regular socks on. R3 Nurse's Note dated 1/19/24 at 6:00 PM by V13 Licensed Practical Nurse documents when V13 first saw R3 on the floor R3 was in a T-shirt and an incontinence brief with no pants on and no socks on R3's feet (barefoot). On 1/30/24 at 11:24 AM, V2 Director of Nursing stated that there was a conflict in stories that R3 did have socks on when R3 fell but they immediately implemented that R3 was to have gripper socks on at all times after this fall. V2 confirmed that R3 is not currently in the facility as R3 had to return to the hospital on 1/22/24. 3.) R4's Care Plan with an updated date of 1/3/24 documents diagnoses including Unspecified Dementia, Weakness, Adjustment Disorder, Unspecified Convulsions, History of falls, history of falls with fractures, Unsteadiness on Feet, Age Related Osteoporosis and Repeated Falls. This Care Plan documents R4 is at risk for falls related to a history of a fall with fracture of the right femur with right hemiarthroplasty, Dementia, A-Fib (Atrial Fibrillation) and Seizure Disorder. This Care Plan documents interventions of a bed and chair alarm due to decreased safety awareness and impulsivity with an initiated date of 4/20/2023 and a non slip mat to the recliner dated 9/22/22. On 1/30/24 at 8:47 AM, R4 was in the recliner in R4's room sleeping with the walker sitting in front of R4. There was no alarm on the recliner. There was a pressure alarm pad with the alarm box on the wheelchair sitting by the door but not on the recliner. On 1/30/24 at 9:18 AM, R4 was still in the recliner in R4's room with no alarm on the recliner. R4 is awake sitting in the recliner. On 1/30/24 at 9:19 AM, V5 CNA stated that R4 is supposed to have the alarm in the recliner but she hasn't gotten it moved to the recliner yet. At this time V5 had R4 stand up with the walker and V5 moved the alarm from the wheelchair to the recliner. The non slip pad remained in the wheelchair and it did not get moved to the recliner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility staff failed to complete wound dressing changes as ordered by the wound care physician. This failure affects one resident (R17) out of five reviewed for wound care on a sample of 18. This failure resulted in R17's foot wounds becoming infested and infected with parasitic fly larvae (maggots) requiring the use of intravenous antibiotics. B. Based on record review and interview, the facility staff failed to obtain and document resident weights as ordered by the physician for relevant medical diagnoses. This failure affects three residents (R1, R16, R17) out of 12 reviewed for physician orders on a sample of 18. Findings include: a. R17's Census Detail and Minimum Data Set List (undated) documents R17 was originally admitted to the facility 6/20/21, with a subsequent re-admission 1/5/22. R17's Nurses Notes dated 9/24/23 document R17 was discharged to the hospital on 9/24/23 due to shortness of breath, low blood pressure, elevated temperature, elevated heart rate, and low oxygen level. R17's current Diagnosis List (undated) documents R17 experiences medical diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Lymphedema, Diabetes, Anemia, Chronic Kidney Disease, Pressure Ulcer of the Buttock, and Need for Assistance with Personal Care. R17's Wound Care Physician Progress Notes from V16, Wound Care Physician, dated 9/20/23 documents R17 was experiencing multiple open draining lymphedema ulcers on both the right and left legs, in durations of between 1 day and 6 months, requiring combinations of calcium alginate, absorbent pads, and compression wraps. This same Progress Note documents R17 was experiencing open draining stage 3 pressure ulcers on both buttocks, in duration greater than 6 months, requiring treatment with absorbent pads and silicone barrier cream. This same Progress Note documents R17 was experiencing and open draining wounds on the right first toe and left first and second toes requiring a treatment procedure to place calcium alginate between R17's toes, absorbent pads, gauze wraps, and compression wraps to be changed twice daily. The treatment orders and dressing changes for R17's right first toe, initially noted on this progress note as a new wound, was not transcribed onto R17's Physician Order Sheet nor onto R17's Treatment Administration Record. This Progress Note documents R17's left first and second toe wounds were not at goal. R17's Nurses Note dated 8/5/23 at 2:29 PM documents R17 had complained that the dressings on his legs had not been changed in a few days. The responding nurse (V11, Registered Nurse) then found maggots in R17's left foot and documented soaking R17's feet in a (sodium chloride solution) and placing secured wraps on R17's feet. There was no documentation that the primary physician nor the wound care physician had been notified of the maggots and new open wounds on R17's left toes. R17's Nurses Note dated 8/7/23 at 5:03 PM documents an (unidentified nurse) notified the wound care physician (V16) about the maggots and new wounds discovered on R17's left toes. At this time V16 ordered for both of R17's feet to be soaked in a (sodium chloride solution) daily for 20 minutes, then twice daily to apply gauze soaked in betadine to R17's left toes and wrap with gauze roll. This dressing order was in effect through 8/18/23 when V16 revised the order to apply calcium alginate and absorbent pads twice daily. R17's historical Physician Order Sheet, undated but only including orders current at the time of R17's discharge to the hospital on 9/24/23 which had discontinue dates of 9/25/23, documents R17 was ordered to receive treatment and dressing changes to the left toes with betadine soaked gauze and gauze wrap every 7 days, initiated 12/21/22 and discontinued 8/18/23. This order was revised to include the daily sodium chloride soaks, and dressings twice daily 8/7/23, after nursing staff notified V16 about the maggots found on R17's left foot on 8/5/23, creating an overlap of conflicting orders from 8/7/23 through 8/18/23. R17's historical Physician Order Sheet, undated but only including orders current at the time of R17's discharge to the hospital on 9/24/23 which had discontinue dates of 9/25/23, documents 2 physician orders, one for R17 to receive skin assessments on shower days every Wednesday and Saturday, and the second for R17 to receive skin assessments on shower days every Tuesday and Friday. This same Physician Order Sheet documents a third physician order for R17 to receive daily skin checks due to being a high risk resident. R17's Treatment Administration Record for September 2023 documents two skin assessment orders, one for shower days on Wednesdays and Saturdays, and the other for daily skin checks. This same Treatment Administration Record documents the nursing staff did not complete the daily skin checks on 9/11/23 and 9/22/23. R17's Medication Administration Record for September documents the third skin assessment order to be completed on shower days every Tuesdays and Fridays. This same Medication Administration Record documents the daily skin check was not completed on 9/22/23. On 9/26/23 at 3:03 PM, V11, Registered Nurse, confirmed, I did see the maggots on (R17's) left foot a while back (8/5/23) and I was assisting R17's primary nurse to soak R17's foot. V11 further stated, I was R17's primary nurse Sunday night (9/24/23) when I had to send him to the hospital. I did get a report from the emergency room that he had maggots in his foot again but I didn't see them this time. On 9/26/23 at 3:25 PM, V16, Wound Care Physician, stated, I am not doing maggot therapy for (R17) but I have heard of that. (R17) had the maggots a couple of months before (8/5/23) and that was why I ordered the treatments for his toes to be twice daily (8/7/23). If the nurses were cleaning and changing the dressings twice per day then there would be no way for maggots to grow in there. V16 continued, After a fly lays eggs it takes a couple of days for the eggs to hatch and the maggots to get big enough to see. This is an indication that the treatments and dressing were not being completed, it's very unfortunate and it looks like some of the nurses are checking off the treatment when they don't do it. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, There was one other time in August (8/5/23) that (R17) had maggots in his foot wounds on his left foot, but at that time he wasn't getting any dressing changes on his feet, just his legs. V2 confirmed, (R17's) shower days are Tuesdays and Fridays. R17's historical Physician Order Sheets document R17 had a physician order for a weekly dressing treatment for the left foot to receive a roll gauze with betadine to be weaved between the toes, initiated 12/21/22 and discontinued 8/18/23. On 9/27/23 at 10:14 AM, V2, Director of Nursing, continued, I do know that (R17) refused his dressing changes on Friday evening (9/22/23) and Saturday for day shift (9/23/23) and if a resident refuses cares or treatment, the staff need to be documenting that. R17's Treatment Administration Record for September 2023 documents 3 incomplete treatments for R17's left toes, one on 9/3/23 on the day shift, 9/21/23 on the evening shift, and one on 9/22/23 on the day shift. These incomplete treatments were left blank as no nurse had completed the treatment or signed the record in any manner. This Treatment Administration Record documents 2 refusals of the left toes treatment by R17, one on 9/4/23 evening shift, and on on 9/22/23 evening shift. There was one treatment record for a referral to the nurses notes on 9/4/23 day shift, however there was not a nurses note at all in R17's record between 9/1/23 and 9/5/23. All other occasions for the twice daily left toes treatment were checked and initialed by nursing staff as though completed, including the day shift on Saturday 9/23/23 which V2 stated R17 had refused. The treatment for R17's right first toe was absent from the Treatment Administration Record which was ordered by V16 on 9/20/23 and was not transcribed to the Physician Orders nor Treatment Record. On 9/28/23 at 8:40 AM, R17 was laying supine in bed at (hospital), visibly pink in the face and obviously short of breath. R17 was utilizing supplemental oxygen running at 1.5 liters per minute through a nasal cannula and the head of the bed was elevated approximately 45 degrees. R17 was receiving intravenous antibiotics Vancomycin and Cefepime. R17 stated, It seemed that the care at (the facility) was better back when I first got there, but since it has changed hands, the care has gone down. V17 continued, I do have some sores on my butt, my legs, and my feet. At (the facility) my legs got wraps that stay on for 7 days, so they take them off on Tuesdays for my showers and that was when the wound doctor (V16) would come in, then on Fridays for my showers they would wrap my legs with bags to keep them from getting wet. I get some creams and salves and pads on my bottom. The nurses were not doing the dressings on my feet twice a day like they were supposed to. R17 further stated, I did not refuse or decline the dressings on my feet, I generally let them do whatever they need to do. There might have been a few times a nurse came to do my dressings and I said I needed to go to the bathroom first, but they never came back to do the dressings, or sometimes they come in after 10:00 PM and I say it's too late at that time. R17 then stated, I did have these maggots one other time about a couple of months ago, the nurse found them, but at that time they weren't putting dressings on my feet at all. Now this time I got them again but they weren't doing the dressings like they were supposed to. These maggots are a bad enough thing but they told me in the emergency room they found some bed bugs on me too. On 9/28/23 at 12:10 PM, V20, emergency room Nurse, stated, I was working when (R17) came to the emergency room this past Sunday night (9/24/23). (R17) did have maggots in his left foot. The maggots were falling out of his foot in clumps. We had to use a suction canister to suck them up as they were falling out. I would say there was maybe 100 of them in all different sizes, some were tiny and some were much larger. It was obvious that the maggots had been there for some period of time because it takes a few days for them to grow to the size that some of them were. These were not like the maggots for actual therapy, those are grown in a lab under extremely sanitary conditions, not from regular house flies around the environment. V20 further stated, The smell around (R17) was atrociously disgusting. I am the first person to know about resident rights but when the smell starts affecting other people, you just have to say 'no' we are going to get you cleaned up because you are affecting other people. My emergency room doctor (V21) was appalled when she saw the maggots and said we have to report this. R17's (hospital) admission History and Physical dated 9/24/23 documents R17 was admitted to the hospital on this date after presenting to the emergency room with several days history of shortness of breath, leg ulcers, maggots, and bed bugs. b. 1. R17's current Diagnosis List (undated) documents R17 experiences medical diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Lymphedema, Diabetes, Chronic Kidney Disease, and Pressure Ulcer of the Buttock. R17's historical Physician Order Sheet, undated but only including orders current at the time of R17's discharge to the hospital on 9/24/23 which had discontinue dates of 9/25/23, documents R17 was to be weighed daily and reported to the physician if there was any weight gains of more than 3 pounds in one day or 5 pounds in one week. This order was documented as initiated 8/26/22 and discontinued 9/25/23 after R17 was sent to the hospital. R17 Treatment Administration Record documents these daily weights were not obtained by facility staff on 9/2/23, 9/3/23, 9/7/23, 9/10/23, 9/11/23, 9/18/23, 9/21/23, and 9/22/23, missing 8 out of 23 opportunities. This same Treatment Administration Record documents R17 had a 4 pound gain from 9/16/23 to 9/17/23, going from 284.6 pounds to 288.6 pounds. There was not a nurses note at all in R17's record between 9/15/23 and 9/19/23 to indicate facility staff had notified R17's physician of the weight gain. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, If a resident has an order for daily weights, like for our residents with CHF (congestive heart failure) then it should be done daily. 2. R16's current Diagnosis List (undated) includes Acute Pancreatitis with Necrosis, Hypertension, Cerebral Infarctions, and Transient Ischemic Attacks (mini-strokes). R16's current Physician Order Sheet (undated) documents a physician order for R16 to be weighed weekly, initiated 2/16/23. R16's Care Plan dated 1/17/23 documents R16 is at risk for nutritional problems, with a nursing intervention documented to weigh as ordered. R16's Weight Record documented R16 was weighed on 1/21/23 at 158 pounds, and 2/1/23 at 159 pounds. R16's Weight Record documents since the initiation of the physician order to weigh R16 weekly on 2/16/23, R16 was weighed on 2/23/23 at 145.3 pounds, on 3/1/23 at 145 pounds, on 3/16/23 at 134 pounds, on 3/30/23 at 135 pounds, on 4/3/23 at 138 pounds, on 4/20/23 at 137 pounds, on 4/27/23 at 137, on 5/1/23 at 133 pounds, on 6/1/23 at 131 pounds, on 6/8/23 at 132 pounds, on 6/29/23 at 132 pounds, on 7/3/23 at 138 pounds, on 7/27/23 at 141 pounds, on 8/3/23 at 143 pounds, on 8/10/23 at 141 pounds, on 9/1/23 at 151 pounds, and 9/21/23 at 157 pounds, having missed 10 out of 28 opportunities for R16's weekly weight from 2/16/23 to 9/21/23, and experiencing significant weight losses and weight gains during the same period. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, If a resident has a physician order for weekly weights, it should be done weekly. 3. R1's Diagnosis List (undated) documents R1 experienced medical diagnoses including Cardiogenic Shock, Coronary Artery Disease, Heart Failure, Peripheral Vascular Disease, hypertension, History of Malignant Rectal Cancer, Anemia, and Radiation Induced Diarrhea. R1's Census Detail (undated) documents R1 was admitted to the facility 7/24/23 and was in the hospital 8/1/23 through 8/8/23, then in the hospital from [DATE] to 8/20/23, and final discharge was 9/7/23. R1's historical Physician Order Sheet (undated) documents a physician order for R1 to be weighed every week for 4 weeks initiated 8/22/23 (for readmission) and discontinued 9/14/23 (after discharge date ). This historical Physician Order Sheet documents a second physician order for weekly weights initiated 7/24/23 (admission date) and discontinued 8/3/23 (after discharge to hospital). R1's Weight Record documents 3 times R1 was weighed, for original admission 7/25/23, on 9/1/23, and 9/7/23, missing a readmission weight from on or around 8/8/23, on or around 8/16/23, readmission on or around 8/20/23, and on or around 8/27/23. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, If a resident has an order for weekly weight, then it should be done weekly. We do initiate orders for weekly weight for four weeks upon admissions and readmissions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to supervise one dependent resident (R9) for safety to prevent a fall, and failed to complete fall risk assessments for three residents (R14, R15, R17) with known fall risks, out of five reviewed for falls and fall risks on the sample of 18. This Failure left (R9) alone sitting on edge of therapy table with no supervision and history of repeated falls, contributing to (R9) falling to floor causing injury and being sent to hospital. Findings include: 1. R9's Census Detail (undated) documents R9 was admitted to the facility 1/10/22. R9's Diagnosis List (undated) documents R9 experiences medical diagnoses including Epilepsy, Repeated Falls, Neuropathy of Right Lower Limb, Cerebral Infarction, Cataracts, Weakness, Need for Assistance with Personal Care, Unsteadiness on Feet, and Cognitive Communication Deficit. On 9/21/23 at 9:25 AM, R9 was seated in the common area by the nurses station on the facility's residential unit 200 Hall. R9 had a large (approximately 4 centimeter) round hematoma with deep purple bruising protruding from the right side of her forehead with dependent deep purple and yellow bruising down surrounding both eyes. R9, obviously exhibiting some level of cognitive deficit, stated, I took a fall outside, I went face down on the cement. I went outside with someone and they weren't with me and I ended up on the ground. (While R9 did not fall outside, she was off of her usual residential unit and in the therapy room of another unit). R9 continued, I did go to the hospital but they really didn't do anything with me, just checked me out and sent me back. R9 further stated, I would think the people would have been more careful with me, but I will live. R9's Minimum Data Set, dated [DATE] documents R9 requires extensive assistance of 2 staff members to accomplish bed mobility, surface to surface transfers, and toileting. This Minimum Data Set documents R9 does not ambulate, and has impairments in range of motion of one upper and one lower extremity. R9's Nurses Notes dated 9/15/23 document R9 had fallen off of the therapy table, incurred a large hematoma to the right forehead, was sent to the emergency room for evaluation, and returned to the facility the same day. R9's Care Plan dated 11/11/22 documents R9 is at risk for falls due to medical conditions of confusion, gait/ balance problems, weakness, history of falls, epilepsy, neuropathy of right lower limb, convulsions, hypertension, and has a history of scooting herself out of the wheelchair. The nursing interventions for fall prevention include to use side rails on the bed, handrails on the walls, chair alarm for safety, and dycem (sticky material) in the wheelchair. On 9/21/23 at 11:05 AM, in the therapy room on the facility's Haven Center Unit was a large (approximately 6 feet by 7 feet) flat padded table without raised edges which was 18 inches off the floor in it's lowest position, and 29 1/2 inches from the floor in the highest position. On 9/21/23 at 1:42 PM, V10, Physical Therapy Assistant, stated, I was working with (R9) the day she fell off the therapy table. I started out working with her doing some range of motion exercises while she was laying flat on the therapy table, then I had her sit up at the edge of the table so I could challenge her to hold her balance while pushing her a little bit side to side. Her legs were over the edge of the table and her feet were flat on the floor and the table was in the lowest position. (R9) was following instructions well and had maintained her sitting balance for about 15 minutes. Then I went across the room to walk with (R18). While I was walking (R18) outside of the therapy room, I didn't see the exact moment of (R9's) fall, but when I got to her she was holding a sock in her hand so I assume she was reaching down and messing with her sock when she fell. R9's Physical Therapy Evaluation dated 9/6/23 documents R9 was dependent for activities such as rolling right and left in the bed, going from lying to sitting on the side of the bed, going from sitting to standing, and transferring from a bed to a chair or toilet. This evaluation documents R9 experiences impairments in range of motion and strength of both right and left lower extremities. This Evaluation documents R9 could not sit unsupported for any amount of time. R9's Occupational Therapy Evaluation dated 9/11/23 documents R9 was dependent for activities such as transfers on and off the toilet, dependent for going from sitting to standing, and received a mobility assessment score of 0 (zero), the lowest possible score. This same Evaluation documents R9 had impairments in range of motion of both right and left upper extremities. This Evaluation documents R9 could not sit unsupported without a moderate amount of assistance for any length of time because R9 began leaning forward, and R9 had no ability to right herself when leaning forward. This Evaluation documents R9 had impaired safety awareness. On 9/27/23 at 2:25 pm, V14, Licensed Practical Nurse, stated, I am familiar with (R9), I would not feel comfortable for one minute leaving (R9) sitting alone on the edge of a bed or on the toilet, I wouldn't let her be any farther away than I could reach. 2:29 pm, V18, Certified Nursing Assistant, stated, Goodness gracious no, I wouldn ' t leave (R9) alone on the edge of a bed or toilet, she tries to get out of any type of sitting position she is in, she wiggles all over to get out of sitting. 2:35 pm, V19, Certified Nursing Assistant, stated, I wouldn't leave (R9) sitting alone on a bed or toilet, she doesn't sit up very well, she leans forward when she is sitting, that's why she is in a (heavily cushioned reclining rolling chair). 2. R14's Census Detail (undated) documents R14 was admitted to the facility 8/13/21. R14's Diagnosis List (undated) documents R14 experiences medical diagnoses including Unsteadiness on Feet, Weakness, Reduced Mobility, Need for Assistance with Personal Care, Lack of Coordination, and Abnormal Gait and Mobility. R14's Care Plan dated 8/13/21 documents R14 is at risk for falls due to multiple medical conditions and diagnoses. On 9/27/23 at 10:14 AM, R14's Assessments (undated) document R14's most recent fall risk assessment was dated 5/13/23. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, We are supposed to be doing fall risk assessments on admission, on readmission, after every fall, and then quarterly. 3. R15's Census detail (undated) documents R15 was originally admitted to the facility 4/19/16, with a subsequent admission 8/23/22. R15's Diagnosis List (undated) documents R15 experiences medical diagnoses including Reduced Mobility, Need for Assistance with Personal Care, and Acquired Absence of (Left) leg Below the Knee. R15's Care Plan dated 8/29/22 documents (R15) has decided to stay at the facility long term due to feeling unsafe being alone because of experiencing dizziness and falls. This same Care Plan documents R15 is at risk for falls related to multiple medical diagnoses and health conditions. R15's Assessments (undated) document R15's most recent fall risk assessments was dated 9/29/22. 4. R17's Census Detail (undated) documents R17 was originally admitted to the facility 6/20/21, with a subsequent readmission 1/5/22. R17's Diagnosis List documents R17 experiences medical diagnoses including Unsteadiness on Feet, Weakness, Reduced Mobility, and Need for Assistance with Personal Care. R17's Care Plan dated 1/7/22 documents R17 is at risk for falls due to multiple medical diagnoses and health conditions. R17's Assessments (undated) documents R17's most recent fall risk assessment was dated 4/30/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician's orders for insulin administration for one (R3) of three residents reviewed for medications in the sample list of ten. This failure resulted in R3 being hospitalized for hypoglycemia. Findings include: R3's Care Plan dated 11/5/22 documents R3 has Diabetes Mellitus and includes interventions to administer diabetic medication as ordered, monitor for side effects and effectiveness of the medication, monitor/document and report symptoms of hypoglycemia and hyperglycemia to the physician. R3's Physician Order with a start date 4/12/23 and end date 5/30/23 documents to administer Humalog (insulin) solution 100 units/milliliter inject 7 units subcutaneously before meals and hold the medication if R3's blood sugar is less than 120. R3's May 2023 Medication Administration Record documents R3 received Humalog 15 times when R3's blood sugar was less than 120, indicating the medication was not held as ordered. R3's Humalog was held or refused an additional 12 times. R3's blood sugar was 63 at 11:00 AM on 5/4/23, the medication was held and refers to R3's nursing notes. There are no nursing notes for this date or documentation that R3's physician was notified of R3's low blood sugar on 5/4/23 or that R3's Humalog was held frequently during the month of May. R3's Nursing Notes document on 5/28/23 at 5:40 PM R3 became unresponsive and was transferred the local emergency room. R3's Hospital Discharge Summary documents the following: R3 admitted on [DATE] at 1:39 AM with diagnoses of Altered Mental Status, Hypoglycemia, and Urinary Tract Infection. R3 was found unresponsive and transferred to the emergency room for concern of symptomatic hypoglycemia. R3's blood glucose was 59 in the emergency room and dextrose was administered by intravenous infusion. R3's mental status may cause R3's meal intakes to be inconsistent and R3's insulin was discontinued. On 6/6/23 at 12:00 PM V3 Licensed Practical Nurse/Nurse reviewed R3's May Humalog order/administration and blood glucose levels, and confirmed R3's insulin was administered when blood sugar was below 120. V3 stated V3 would expect the nurses to hold the insulin per blood sugar parameters and notify V5 Nurse Practitioner if the insulin is held frequently. V3 stated R3 was recently admitted to the hospital and R3's insulin was changed to oral diabetic medication. On 6/6/23 at 12:05 PM V5 Nurse Practitioner stated if the nurses were frequently holding R3's insulin V5 would expect to be notified to review and possibly adjust R3's insulin dosage. V5 did not recall being notified of R3's blood sugars or to review R3's insulin in May 2023. V5 stated V5 would have entered a progress note. V5 stated if the nurses had held R3's insulin as ordered and notified V5, it may have prevented R3's hospitalization. The facility's Medication Administration Policy dated March 2014 documents Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow physician ordered fall interventions for one of four residents (R25) reviewed for falls/accidents on the sample list of 25. Findings include: R25's Diagnoses List documents the following: Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Depression, Difficulty in Walking, Unsteady on Feet. R25's Clinical Physician Order Sheet (POS) dated 12/31/22-1/31/23 documents the following: Helmet to be worn when up out of bed, every shift for injury prevention and Hip protectors on at all times except during personal care every shift for fall intervention. R25's Minimum Data Set (MDS) dated [DATE] documents R25 has severe cognitive impairment. and requires supervision and set up for ambulation in room and corridors. The same MDS documents R25 has had two or more falls in the facility. R25's Care Plan updated 11/18/22 documents the following: Focus: (R25) is HIGH risk for falls r/t/ dx of (related to diagnosis) Dementia, COPD (Chronic Obstructive Pulmonary Disease), HTN (Hypertension), Weakness, GERD, abnormalities of gait/mobility, lack of coordination, hypokalemia, anemia, dysphagia, cognitive communication deficit, difficulty walking, HLD, depression, and osteoporosis.) Goal: (R25) will be free of minor injury through the review date. Intervention/Tasks: Hipsters to be worn for protection at all times. 04/16/22 PT/OT (Physical Therapy/Occupational Therapy) eval Evaluation) post fall and place helmet for safety 08/24/2022: (R25) will repeatedly take her helmet off and becomes agitated and aggressive at times when staff tries to place helmet on. On 01/10/23 at 01:15 pm an unidentified Certified Nursing Assistant (CNA) assisted R25's room and assisted R25 to lay down in low bed that was up against the wall. The unidentified CNA exited R25's room. R25 was layed in a fetal-like position in bed, facing the wall with a full hard shelled football-like helmet on. The helmet was strapped under R25's chin. R25 was tugging at the chin straps as R25 lay in a fetal-like position facing the wall. R25 was non-verbal and mumbled when interviewed. On 01/10/23 at 1:30 pm R25 continues with the hard shelled football-like helmet on in bed. R25 was trying to take off helmet, fidgeting repeatedly with the chin strap, tugging at the hard shell and intermittently picking motions hitting the wall next to bed in rapid succession while mumbling. On 01/10/23 at 1:40 pm R25 continues with helmet on while in bed. R25 was more restless and was scratching the wall assertively intermittently while tugging forcefully under chin helmet strap On 01/10/23 at 1:42 pm V4, CNA stated We just leave it (helmet) on when she is in bed because she has had falls. When she (R25) is asleep overnight they take the helmet off then. V4, CNA also stated I don think she has ever worn hipster. Not that I know of. On 1/10/23 at 1:55 pm V3, Licensed Practical Nurse (LPN) entered R25's room. R25 was tugging on the chin strap of her helmet. V3, LPN assessed R25's for the presence of hipsters by touching outside R25's pants, across R25's hips. V3, LPN then pulled the side of R25's pants to reveal R25's incontinence brief and bare thigh. [NAME] stated (R25) is only suppose to wear the helmet when out of bed. I will take that off. She (R25) can rest more comfortably without that (helmet) on. I don't know why she (R25) doesn't have the hipsters on. They are to be on except when she is being changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision and toileting assistance for one (R6) of three residents reviewed for falls. This failure resulted in R6 falling and sustaining a right hip fracture, right orbital (eye socket) fracture, and right wrist fracture. The facility also failed to implement post fall interventions for one (R6) of three residents reviewed for falls in the sample list of six. Findings include: R6's Diagnosis List dated 1/3/23 documents R6 has Dementia. R6's Minimum Data Set, dated [DATE] documents: R6 has a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. R6 requires limited assistance of one staff person for transfers, walking, dressing, and toileting. R6 uses a walker, is not steady, and only able to stabilize balance with staff assistance when turning around, moving on/off the toilet, and for surface to surface transfers. R6's Care Plan dated 11/7/22 documents R6 is at risk for falls related to confusion, gait/balance problems, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Osteoporosis, overactive bladder, and reflux disease. R6's care planned fall interventions do not include the use of an alarming device. R6's Nursing Notes document the following: On 12/15/22 at 12:46 PM R6 had an unwitnessed fall in a resident room. R6 was found lying on the floor holding R6's head. R6 had a laceration to R6's right eye, right face 5 cm (centimeters) long by 1.27 cm wide by 0.3 cm deep, right wrist, and right forearm 3.5 cm long by 1 cm wide by 0.1 cm deep. R6's right wrist was flaccid (limp). R6's right eye was swollen shut and R6 was unable to open R6's eye. This nurse (V10 Licensed Practical Nurse) applied pressure with ABD (abdominal) pads to orbital socket to stop hemorrhaging. R6 was transported by ambulance to the emergency room. Contributing factors include R6 was not using R6's cane/walker as instructed and R6 has diagnoses of Dementia and an unsteady gait. R6's undated Fall Investigation documents the following: R6's fall occurred in another resident room. V11 Certified Nursing Assistant (CNA) saw R6 in the bathroom approximately 3 minutes prior to the fall. V11 thought R6 was trying to put on different pants because resident's (R6's) pants were in the bathroom. R6 requires limited assistance of one person for activities of daily living and transfers. Root Cause: it is probable resident (R6) was attempting to dress without assistance resulting in (R6) becoming off balance and falling. Based on investigation, it is probable that resident (R6) took herself to the bathroom and took off her pants. Resident (R6) had a different pair of pants around her ankle upon staff assessment. R6 was transferred to the emergency room and diagnosed with a right hip, wrist, and orbital bone fracture. R6's Hospital emergency room Note dated 12/15/22 at 1:32 PM documents R6 had an unwitnessed fall at the nursing home and presented with right eye bruising/bleeding, right hip pain, right facial injuries, and fractured right wrist. R6's right wrist x-ray and right hip x-ray dated 12/15/22 document There is an acute dorsally impacted fracture distal metaphysis of the radius. There is an acute avulsion fracture styloid process distal ulna. Right hip x-ray shows a fracture in the subcaptial region extending to the mid cervical region medially. Acute pathology is right wrist fracture and right hip fracture. R6's head/facial bone Computed Tomography scan dated 12/15/22 documents Right orbital rim fracture. On 12/29/22 at 10:52 AM R6 was lying in bed on a motion sensor bed alarm. R6 had a cast to R6's right forearm and bruising/scabbed area to R6's right check. R6 did not remember falling and was unable to recall details of R6's fall. At 11:15 AM V12 and V6 CNAs used a gait belt and transferred R6 from the wheelchair into the shower chair. R6 had dark blue bruising to R6's right side and lower back/hip. At 1:51 PM R6 was sitting in a recliner in R6's room. R6 did not have a motion sensor alarm in R6's recliner. On 12/29/22 at 1:54 PM V12 CNA stated V12 was not sure who transferred R6 into the recliner. V12 confirmed R6's recliner did not have a motion sensor alarm. I put one (alarm) in (R6's) chair this morning and (R6) uses it (alarm) in bed. We have a binder at the desk that tells us fall interventions/alarms. On 12/29/22 at 1:57 PM the fall intervention binder did not contain information regarding R6's fall interventions. V9 Licensed Practical Nurse (LPN) confirmed the binder did not contain fall interventions for R6. V9 stated V9 was not sure if R6 uses motion sensor alarms and V9 would have to look up the information. V9 reviewed R6's Physician Orders and stated there is no order for R6 to have an alarm. There would be an order if (R6) was suppose to have one. On 1/3/23 at 10:18 AM V11 CNA stated: V11 was walking with R6 to the dining room (on 12/15/22). R6 told V11 that R6 needed to go to the bathroom. V11 told R6 to go ahead and go to the bathroom, and V11 would return later. V11 went to assist another employee with a resident transfer, and upon return R6 was found on the floor near the closet of another resident's room. V11 had last seen R6 sitting on the toilet in the adjoining bathroom of that room a few minutes prior. R6 was found to have on different pants that did not belong to R6. R6's walker was in the bathroom and not in the resident room near R6. V11 does not work R6's hall much, but R6 was pretty independent with toileting. The post fall intervention was not to leave residents in the bathroom by themselves. R6's fall probably could have been prevented if someone was in the bathroom assisting R6. R6 gets confused and mixed up. R6 was in the closet getting clothes to change into, because R6 was incontinent. On 1/3/23 at 10:45 AM V10 LPN stated V10 heard a scream and found R6 lying face down in another resident room. R6 was bleeding, R6's orbital socket had a big gash and R6's right wrist was limp. V10 supported R6's wrist with R6's fingers. R6 was unable to open R6's right eye due to swelling and a hematoma. Prior to the fall R6 was confused, had an unsteady gait, and required assistance of one staff person for transfers, ambulation, and toileting. R6 was not safe to be left in the bathroom by herself due to R6's confusion. On 1/3/23 at 1:25 PM V2 Director of Nursing stated R6 should have a motion sensor alarm in use when R6 is sitting in the recliner in R6's room. This information should be updated on R6's care plan and included in the binder at the nurse's station. V2 stated through investigation it is probable that R6 was attempting to pull up R6's pants that R6 had obtained from the room and fell. V12 stated V11 had witnessed R6 in the bathroom approximately 3 minutes prior to the fall, and staff should assisted R6 since R6 required one assist for activities of daily living. On 1/3/23 at 2:39 PM V4 Physician confirmed R6's injuries are consistent with a fall. The facility's Falls - Clinical Protocol revised August 2008 documents: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.