**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transcribe physician orders for comfort care medications for a resident admitted to hospice care services. This failure affected one (R1) of five residents reviewed for physician orders and resulted in R1 having untreated pain for several days before expiring in the facility. Findings include: R1 was originally admitted to the facility [DATE] with diagnoses that included but are not limited to malignant colon cancer. According to R1's electronic health record, progress notes of [DATE] indicate R1 went to an outpatient oncology appointment and was hospitalized with a diagnosis of adult failure to thrive. While in the hospital, and due to R1's sudden decline in health, R1's healthcare proxy elected for R1 to admit to hospice services upon returning to the facility. Consent for hospice services was signed in the hospital on [DATE]. R1 returned to the facility [DATE]. According to nurse progress notes, V3 LPN (Licensed Practical Nurse) received R1 upon arrival, and transcribed orders received from the hospital. An order for hospice services was written on the Physician's Order Sheet [DATE]. On [DATE] at 9:10am V9 (R1's Representative) said they went to visit R1 on [DATE]. V9 stated walking in R1's room, V9 noticed that R1's face was contorted in pain, and R1 was gripping the sheets. V9 stated, since the hospitalization, R1 was confused and would often say no to anything R1 was being asked. When V9 saw R1's presentation, V9 immediately went to find a nurse, however the nurses were not immediately available at the nursing station. V9 saw an unidentified staff member enter the room and relayed the concern of R1 showing overt signs of pain. V9 and the staff member found the nurse on duty (V10 LPN), V9 stated V10 relayed that R1 had morphine on hand and showed it to V9. However, V10 stated there was no order written and therefore could not administer it to R1. V9 stated, the nursing manager (V2 Director of Nursing) got involved and got an order for R1 to receive the medication and the nurse gave it. During this interview, V9 began crying and stated my biggest heartache is that [R1] sat there in pain before he died in the facility. [R1] had been [in the facility] since Sunday, and Thursday was the first time he got morphine and then on Friday ([DATE]), [R1] died. According to hospice notes, R1 was assessed by a hospice nurse and admitted to hospice services the following day of readmission on [DATE]. Written hospice orders included comfort kit medications orders which included morphine sulfate for pain, lorazepam for anxiety and restlessness and acetaminophen suppositories for fever and pain. Hospice RN (Registered Nurse) and facility nurse V7 LPN signed that orders were reviewed and received. At the time of this survey, review of Physician's Order Sheet for [DATE] did not include any transcription of the hospice orders for medications. V6 is representative from the hospice company caring for R1. On [DATE] at 3:40pm V6 stated R1 was transferred to the facility over the weekend, and the (hospice) nurse came to assess and admit R1 to hospice the following day [DATE]. While the nurse was at the facility, medication and other orders were confirmed with the facility nurse on duty for R1. V6 stated the nurse was identified as V7 as evidenced by name and signature on the admission forms. V6 stated the hospice company provides the comfort kit medications from a collaborating pharmacy and the medications usually arrive before or at the time the admitting nurse comes so that the medications are available to be reviewed during admission. V6 also provided a pharmacy sheet manifest that listed V8 LPN as receiving medications from the hospice pharmacy. The medications delivered included five milliliters of Morphine Sulfate 20mg/ml (milligrams/milliliter) solution received by V8 on [DATE] at 1:49pm. Hospice Comprehensive Assessment notes that the admitting hospice nurse's time in was for 1:50pm, and time out 3:00pm. Hospice Chaplain noted visiting R1 on [DATE]. Hospice Support Services Log written by the chaplain included a care plan open for pain. During the Chaplain visit R1 was noted to exhibit signs of pain: [R1] reports no, grimacing with anticipation. R1's Nursing Progress Note dated [DATE] at 5:32am stated [R1] observed with shortness of breath while lying flat, resident repositioned, head of bed elevated Vital signs taken, [oxygen] given via [nasal cannula]. [R1] appears comfortable at this time, will continue to monitor. Resident recently enrolled in hospice services. will continue to monitor. On [DATE] at 11:53am V2 DON (Director of Nursing) stated, they were not aware of any concern related to R1's pain medication not being available, however remembered helping the nurse on duty with orders on [DATE]. V2 stated the nurse (V10 LPN) was fairly new and we had to call hospice directly for the orders because R1 didn't have any orders for the morphine documented in the electronic health record. V2 stated they didn't know if the medication was available, and I didn't ask but I did put the orders in the [electronic health record]. V2 went on to say, at the time of the hospice nurse's assessment of the residents admitting to hospice care, facility nurses are expected to review any new orders provided by hospice relay them to the primary provider and transcribe the orders onto the Physician Order Sheet. Nurses are then expected to write a progress note indicating this action. Working nursing schedules were reviewed and confirmed V7 LPN and V8 LPN as the nurses working R1's unit the 7am-3pm shift on [DATE]. On [DATE] at 3:33pm V7 LPN stated the unit was short one nurse that day and it was likely very busy. V7 recalled taking care of R1 on [DATE] but did not recall receiving hospice orders. On [DATE] at 12:07pm V8 LPN stated they could not recall working the unit that morning and did not recall receiving medications for R1. The Physician Order Sheet indicated three orders documented by V2 on [DATE] at 11:03 for Morphine Sulfate: Morphine Sulfate (Concentrate) Solution 20 mg/ml (milligram/milliliter) Give 5 mg by mouth every 2 hours as needed for moderated Pain give 5mg; Morphine Sulfate (Concentrate) Solution 20 mg/ml Give 10 mg by mouth every 2 hours as needed for Severe Pain Give 10mg(0.5ml); Morphine Sulfate (Concentrate) Solution 20 mg/ml Give 5 mg by mouth every 1 hours as needed for dyspnea/ air hunger/ shortness of breath/ respiratory rate give 5mg. Policy for Transcription of Physician Orders no revision date states in part: Purpose: 1. To establish the procedure by transcribing new physician orders. 2. To document and give clear indication that physician orders have been processed and action taken. admission Protocol or Return From Hospital Stay: 1. Transcription of physician order: a. Carefully, review transfer record and discharge summary from the hospital or the transfer record from another health care facility. B. The licensed nurse should notify the physician of the resident's admission, clinical condition and findings, review and clarify transfer orders and previous orders, as applicable. C. After each order is entered in the Physician Order tab of the chart, check that all orders were entered correctly. D. After physician verification, the licensed nurse completes a progress note that denotes the physician is aware of the admission and that the orders were verified. 6. Medication and treatment orders are to be transcribed in the physician order tab of the electronic medical record. Directions must be understandable (without abbreviations other than the approved abbreviations) by all staff members who are responsible for medication and treatment administrations. Hospice Services Agreement contract with the facility signed [DATE] states in part [hospice provider] shall also provide all prescription drugs, pharmaceuticals, medical equipment and supplies relating to a resident Hospice Patient's terminal illness as may be specified in such Resident Hospice Patient' Plan of Care. Services to be provided by Nursing Facility: A. Room and Board. 1. Nursing Facility shall provide Room and Board services in the form of personal care services to each Resident Hospice Patient. It is nursing Facility's responsibility to continue to furnish 24-hour room and board care, meeting the personal care and nursing needs that would have been provided by the primary giver at home at the same level of care provided before hospice care was elected. Such Room and Board services shall include but not be limited to such services as: 3- Administration of medication as prescribed in the Plan of Care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident safety by failure to provide two persons assist to a totally dependent resident (R121) when providing incontinence care. This failure resulted R121 falling from bed that required a visit to the hospital for evaluation and repair of a laceration to the scalp which needed three staples. This deficiency affects one (R121) of three residents in the sample of 32 reviewed for Resident safety/Fall Prevention Program. Findings include: On 11/20/24 at 10:03AM, V30 Family member stated the facility failed to provide adequate care and supervision causing R121 to fall while receiving care. R121 fell from bed resulting in a head laceration. R121 legs are contracted and laid still. On 11/20/24 at 10:30AM, V1 Administrator and V2 Director of Nursing (DON) stated that R121 fell from bed on 11/4/24 during incontinence care provided by V29 Certified Nursing Assistant (CNA). On 11/20/24 at 10:48AM, R121 lying in bed with low air loss mattress. She (R121) is nonverbal. R121 has a Tracheostomy connected to oxygen at 3LPM (liters per minute). R121 has Gastrostomy tube connected to Glucerna 1.2 feeding tube at 65ml/hour. She is totally dependent of ADLs (Activity in Daily Living) and transfers. Review of R121's incident report submitted to the State Agency on 11/5/24 indicated: Date of incident: 11/4/24 at 6:30AM. Witnessed fall with physical harm or injury. V29 CNA written statement indicated she was providing ADL care to resident. As she rolled R121 over to provide incontinence care she began to slide out of the bed. She called for assistance from V25 LPN (Licensed Practical Nurse). Observed R121 on the floor in a side lying position. Noted moderate blood to the posterior scalp. Bleeding controlled. No loss of consciousness (LOC) noted. Neuro check initiated with no deviation from baseline. ROM (range of motion) done to all extremities and were within normal limit. Physician made aware and ordered to send R121 to hospital for evaluation. V30 Family member notified. R121 returned to facility with three staples to right lateral head. R121's hospital records dated 11/4/24 indicated: Witnessed fall from her bed and hitting her head. Per EMS (Emergency medical services), staff reports that the R121 was being cleaned up by staff and she rolled off her bed. Staff reports R121 has no LOC and has laceration to the head. R121 non-verbal at baseline. Clinical impression: Laceration of scalp, Fall. Physical exam: 2 cm laceration to the right sided parietal scalp without active bleeding or surrounding erythema. Laceration repair: three staples to right parietal scalp. R121 is re-admitted on [DATE] with diagnoses listed in part but not limited to Anoxic brain damage, Chronic respiratory failure with Hypoxia, Tracheostomy, Gastrostomy, Dysphagia. Comprehensive care plan indicates she has an ADL self-care performance deficit related to disease process of anoxic brain damage, dependent for ADLs and mobility, incontinent of bowel and bladder. She has contractures to all extremities. She is at risk for falls and fall related injuries related to decreased mobility and impaired balance. Most recent MDS/Resident assessment dated [DATE] section GG Functional abilities: GG0130 Self-care indicated: Toileting hygiene, Shower/bathe self and Personal hygiene coded as 01-Dependent- helper does all of the effort, Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. GG0170 Mobility indicated: Roll left and right coded as 01- Dependent- helper does all of the effort, Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. On 11/20/24 at 1:48PM, V1 Administrator stated that they don't have policy on Resident safety. On 11/21/24 at 10:22AM, V25 LPN stated he was working with R121 when she had the fall incident while V29 CNA was providing incontinence care. V25 stated that R121 is totally dependent in ADLs and needed two person assist with mechanical lift transfers. V25 stated that he did not witness the fall incident. V25 stated that V29 CNA should have pulled R121 toward her or closer to her instead of rolling R121 away from her for safety. On 11/21/24 at 10:49AM, V26 Nursing Supervisor 11-7 shift stated she was called by V25 LPN to R121's room. V26 stated, she observed R121 in a lying position and observed laceration to scalp. V26 stated they controlled the bleeding. Physician and family were notified of the incident. R121 was sent to the hospital for evaluation. R121 returned with staples to the lacerated scalp. V26 stated that they did in-service the nursing staff of proper position/transition during incontinence care. V26 stated that for resident safety, CNA should get assistance of two persons to assist dependent resident for incontinence/ADL care. V29 CNA should pull R121 towards/ closer to her to prevent R121 slipping from edge of the bed. On 11/21/24 at 11:23AM, V29 CNA stated that she was providing incontinence care with R121, when she slid off the bed. V29 stated that she should have pulled R121 towards/closer to her instead of rolled her away from her placing her at edge of the bed. On 11/21/24 at 12:02PM, V27 MDS/Restorative Nurse stated that she did the MDS/Resident assessment of R121. V27 stated R121 is totally dependent with ADLs and transfers. Section GG functional abilities indicated that she needs two assists with bed mobility- roll to left and right side and personal hygiene and grooming. On 11/21/24 at 1:20PM, V2 DON stated that they did in-service the nursing staff regarding proper and safe positioning and bed mobility to dependent resident such as ensuring that there is as adequate number of caregivers present to safely position or move the patient. V2 stated, when providing ADLs/incontinence care in bed that staff should roll/pull the resident toward /closer to them to prevent placing resident at the edge of the bed and avoid slipping out of bed. Facility unable to provide policy on Resident Safety. Facility's policy on Fall Prevention Program revision 11/21/17 indicates: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Facility's tips for positioning a patient in bed: The process of positioning a patient in bed should be smooth, safe, and comfortable for both the caregiver and patient. * Ensure that there is an adequate number of care givers present to safely position or move the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect resident rights to be free from physical abuse by staff. This failure affected two (R1 and R2) of four residents reviewed for abuse and resulted in R1 sustaining swelling and redness to her left eye and being transferred to a local hospital to rule out orbital fracture and R2 sustained redness to his face after being slapped by a staff. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, past medical history includes, but not limited to: cerebral palsy, spastic hemiplegic cerebral palsy, paroxysmal atrial fibrillation, vascular dementia, essential primary hypertension, encounter for attention to colostomy, anemia, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, hypotension, etc. On 9/5/2024 at 10:25AM, R1, who just returned from the hospital was observed in her room, awake and alert and was being assisted with ADL (activities of daily living) care by V10 (restorative aide). R1 was asked why she went to the hospital, and she R1 stated, the two CNA's (certified nursing assistant) hurt me, one was on the right side and was twisting my hand and fingers, the other was on the left side hitting me with the remote control. R1 tried to demonstrate what happened by twisting surveyor's fingers and used her bed remote control to demonstrate how the CNA hit her face. R1 was noted with some dark purplish bruising to her right hand, some redness to her left cheek under the left eye and a little swelling around the left eye. Progress note dated 8/31/2024 at 9:32AM documented that R1 was noted with swelling and discoloration to her left eye, patient complained of some pain and pain meds were given. Attending physician who was on ground was notified, ordered for the resident to be sent out to a local hospital. Physician progress note dated 8/31/2024 at 12:10PM states in part: patient seen and examined, patient is complaining of swelling and pain on the left eye patient stated that somebody had hit her. No fever or chills, patient states she cannot move her left eye, will send patient to the hospital for evaluation of possible orbital fracture. Facility reported incident dated 8/31/2024 documented in part that R1 was noted with discoloration to her left eye, and she described the two staff that she alleged caused her the injury while providing her with ADL care. Police report dated 8/31/2024 documented that police responded to the facility for a delayed battery report. In the report, R1 was named as the victim and V6 (CNA) and V7 (CNA) named as the suspects. According to the police report, R1 reported that one staff slapped her across the face and the other one twisted her right hand and fingers, resident was noted with discoloration and swelling to her face and bruising to her right hand. Hospital record dated 8/31/2024 documented as chief complaint that R1 presented with an allegation of being hit in the face with a remote and staff twisting her fingers at the nursing home. 9/4/2024 at 1:22PM, V4 RN (registered nurse) stated that she came to work on 8/31/2024 and was making rounds around 7:15AM when she noticed R1's leg out of the bed, she asked another nurse to come and help her reposition resident. R1 reported that she was abused by two staff members (CNAs), but she does not know their names. V4 had not seen or heard R1 making such an allegation in the past. V4 confirmed that R1 was complaining of pain to her hands and left eye. V4 noticed some bruising and swelling to R1's left eye and bruising to her left hand that was purplish/blue in color. 9/4/2024 at 2:09PM, V8 MD (medical doctor) stated that he came to the facility to see R1 and noticed some swelling in her left eye and that the resident stated that 2 CNAs abused her and she was complaining of pain. V8 also noted small redness inside resident's eye and decided to send her to the hospital for further evaluation. V8 added that the redness and swelling also could result from an infection or abuse but he is not sure, he did not check resident's hands, he saw the resident before going on vacation and she did not have the redness. V8 added that R1 has never made any abuse allegation in the past, the redness and swelling was new and resulted from a recent incident. 9/4/2024 at 3:41PM, V2 DON (director of nursing) stated that she was called by a staff between 7:00 - 8:00AM and was notified that R1 said that she was hit by someone. V2 went to resident's room and noted some discoloration to her left eye. 9/4/2024 at 3:59PM, V1 (Administrator) stated that R1 has a behavior of throwing herself on the floor, removing her colostomy bag, etc. to get attention. Both CNAs denied hitting R1. Review of medical records did not show any documentation of R1 ever accusing any staff of abuse before this incident. R2 is an [AGE] year old resident with past medical history that includes: metabolic encephalopathy, acute kidney failure, unspecified injury of head, urinary tract infection, major depressive disorder severe with psychotic symptoms, hyperlipidemia, dysphasia oropharyngeal phase, alzheimer's disease, parkinson's disease, depression, anxiety disorder, etc. On 9/3/2024 at 11:15AM, R2 was observed in his room, awake, alert, and oriented with some confusion. R2 recalled being slapped on his face by someone but does not recall exactly what happened. Progress note dated 8/9/2024 documented that resident was noted with redness to the side of his face, resident denied pain, MD and family notified. Facility reported incident dated 8/9/2024 documented that the administrator was notified that R2, and a nurse practitioner (V11) were involved in a physical altercation, body assessment completed, resident noted with redness to right side of face, no complaints of pain, MD, family, and police were notified, police report completed. The report concluded that R2 was abused by V11 who was reported to her employer group and is no longer employed at the facility. Police report stated that police responded to the facility for a delayed battery. R2 was listed as the victim and V11 (Nurse Practitioner) as the offender. The same report documented that V11 admitted being at fault, stating that she was suffering from multiple problems at the time. Review of the training provided to V11 by the facility did not list any training on abuse. V11 completed training on infection control, HIPAA (health insurance portability and accountability act, antimicrobial stewardship, do not abbreviate, etc. 9/4/2024 at 12:54PM, V3 LPN (licensed practical nurse) stated that she was in the building the day R2 had an incident with a staff, she just got out of the elevator and saw R2 agitated, the nurse practitioner (V11) was trying to calm R2 down, but he became more agitated. Staff moved resident to another part of the nursing station, R2 started using vulgar terms stating V11 struck him. Resident was noted with some redness to the right side of his face, he did not require any medical treatment and denied any pain. 9/4/2024 at 3:59PM, V1 (Administrator) stated that she completed the abuse investigation for R1 and R2. For R2, the conclusion was that V11 became aggressive with the resident and was escorted out of the building immediately. The facility does not provide abuse training to non-staff, V11 is not a staff of the facility but part of a provider group, the facility is not responsible for training her on abuse. 9/4/2024 at 3:41PM, V2 (DON) state that she spoke to V11 (NP) who admitted hitting the resident and was complaining of being overwhelmed. R2 is not aggressive, he is alert and oriented with some confusion. Facility abuse prevention and reporting policy revised 1/22/2019 states in guidelines that the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Under orientation and training, the document states in part that during the orientation of new employees, the facility will cover at least the following: sensitivity to resident's rights and resident's needs, what constitutes abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a treatment plan for (R4) who was identified as very high risk for skin break down, admitted with an opening on the penile shaft, excoriation on the penile head/tip with the penile prosthesis in an erectile position for twenty-two days. This failure resulted in R4 sustaining a facility acquired full thickness, moisture associated skin dermatitis (MASD) measuring 8.00 centimeters (cm) x 3.00 (cm) x 0.10 (cm) (L x W x D) for one of three reviewed for wound care in a sample size of ten. Findings Include: On 7/19/24 at 12:58PM, V6 (treatment nurse) stated, MASD is caused by moisture (urine, stool, sweat and or body fluids) which would cause a break in skin due to repetitive movements or friction. R4 was admitted with a penile implant that was fixed and erect. It would not go down. We had to ensure his adult brief was in place a certain way to prevent friction. V6 stated, she was not sure what that certain way R4 adult brief was place. R4 started to have skin break down to the penis, the doctor was notified. R4 needed to have surgery to have the rod removed. V6 stated, she was not aware of what type of penile implant R4 had, how to deflate the implant, R4 did not go out on any appointment or to the hospital for the implant and was discharged before we could establish anything. On 7/19/24 at 2:45pm, V9 (ADON/assistant director of nursing) stated, R4 did not have a treatment in place upon admission for his penis. V9 stated, R4 had a photo of his penis on admission that showed an opening on the shaft and excoriation on the head/tip. V9 stated, R4 should have had a treatment put in place, the doctor should have been notified and the site should have been measured upon admission. R4 had a treatment put in place on 3/11/24. On 7/24/24 atn3:41pm, V38 (wound doctor) stated, he saw R4 once or twice. Full thickness is the third layer of skin loss. V38 stated, the facility should have been monitoring R4 for any type of skin break down. R4 needed surgery. V38 stated, he does not have any more information on R4. Hospital referral paperwork dated 2/14/2011 documents: R4 prosthesis left in the semirigid position. Nursing note dated 3/11/24 documents: R4 has a pressure injury noted to his penis. Physician order sheet date 3/11/24 document: Wound care: Penis clean with normal saline and apply zinc. Wound assessment dated [DATE] documents: R4 had a facility-acquired moisture associated skin damage. Classification: Incontinence. Stage: Full thickness. Size (cm) 8.00 x3.00 .0.10 (L x W x D). Area 24.00cm. Air loss mattress noted in place. Resident has a penile prosthesis that is fixed, erected is incontinent of bowel and bladder. Wound doctor visit dated 3/14/24 documents: wound#5. Penis is a partial thickness abrasion and had received the status of not healed. Initial wound encounter measurements are 2cm length x 2 cm width x 0.1 cm depth, with an area of 4 square cm. scant amount of sero-sanguineous. According to the national pressure injury advisory panel a stage 3 Pressure Injury is defined as a Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Pressure Injury and Skin Condition assessment dated [DATE] documents: to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify and treat pressure ulcers for a resident dependent on staff for care. This affected one of three residents (R4) reviewed for pressure ulcers. This failure resulted in R4's pressure ulcers not being found/treated until they were an advanced stage on 10/17/23, 3/21/24 and 4/11/24. The findings include: R4's face sheet printed on 5/24/24 shows that R4 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Acute and Chronic Respiratory Failure, Tracheostomy, Gastrostomy, Dependence on Ventilator, End Stage Renal Disease, Dependence on Renal Dialysis, and history of Sudden Cardiac Arrest. R4 was discharged from the facility on 4/29/24 to the hospital and was not in the facility on 5/24/24. R4's Shower Form dated 10/17/23 shows that R4 has skin tears to her sacrum, posterior right thigh, and right ear. A handwritten comment on this form states, open areas noted. R4's Wound assessment dated [DATE] shows that R4 developed a facility acquired Deep Tissue Injury measuring 7 x 8 x Unknown cm that was 90% deep maroon in color and 10% pink or red non-granulating tissue. (R4 was last readmitted to the facility from the hospital on 9/11/23) R4's Initial Wound Physician Progress Note dated 10/20/23 states, Wound #1 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 6 cm length x 4 cm width x 0.1 cm depth . There is a light amount of serosanguineous drainage noted which has no odor. Wound bed has no granulation, 100% slough . On 5/24/24 the facility provided two Shower Forms both dated 3/21/24. The first form shows that R4 has four open areas, sacrum, left elbow, right heel, and left heel. This form also shows that R4 has a G-tube (Gastrostomy). This form is signed by a CNA and a nurse. The second Shower Form is dated 3/21/24 and shows that R4 has an open area on her right elbow and is signed only by a nurse. R4's Wound assessment dated [DATE] shows that R4 developed a facility acquired Unstageable wound to her left elbow measuring 1 x 1.5 x Unknown cm that is described as 50% bright pink or red and 50% necrotic soft, adherent. R4's Wound Physician Progress Note dated 3/22/24 does not address R4's left elbow. R4's Wound Physician Progress Note dated 3/29/24 states, Left elbow is a stage 3 Pressure Ulcer and has received a status of Not Healed. Initial Wound encounter measurements are 1 cm length x 1 cm width x 0.1 cm depth .There is a light amount of serous drainage noted which has no odor. R4's Treatment Administration Record shows the first treatment was applied to R4's left elbow on 3/23/24. (Wound found on 3/21/24) On 5/24/24 the facility provided two Shower Forms both dated 4/11/24. The first form shows that R4 has seven open areas (none on her right lateral foot), a Tracheostomy/trach and a Gastrostomy/Gtube. This form is signed by a CNA and a nurse. The second Shower Form also dated 4/11/24 shows that R4 has only one open area on her right lateral foot This form is signed only by a nurse. R4's Wound assessment dated [DATE] shows that R4 developed a facility acquired Deep Tissue Injury measuring 2.1 x 1.8 x unknown cm. The wound is described as a 100% blood filled blister. R4's Specialty Wound Evaluation and Management Summary dated 4/22/24 shows that R4 has an Unstageable DTI (Deep Tissue Injury) measuring 1.7 x 1.5 x Not measurable cm to her right lateral foot. The wound is described as intact with purple/maroon discoloration. On 5/24/24 at 11:40 AM V17 (LPN- Wound Care Nurse) stated that R4 had 5 pressure sites at the time of her discharge. V17 stated, We do our own assessment and then we contact the wound care physician. It would be expected that the staff notify us before seeing the wound becoming a deep tissue injury. The sacral wound, the left elbow and the right lateral foot were all found during treatment of other wounds by a treatment nurse. (R4) did not move at all and she had contractures. Our skin assessments are done 2x/times a week during the showers the CNAs have the nurse come and do a skin check. R4's Care Plan Initiated on 6/30/23 states, (R4) has active skin issues and remains at high risk for further skin breakdown related to her diagnosis of anoxic brain damage, respiratory failure, End stage renal disease with dependency on dialysis, diabetes, dependency on trach and Gtube, immobility, total dependence. The interventions for this focus include Document: if skin is intact. If skin is reddened or has open areas. Report any new openings to Registered Staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R3 was admitted with the diagnosis with muscle wasting and atrophy, reduce mobility, lack of coordination, abnormal posture, weakness, hemiplegia affecting left non-dominant side. Minimal data set section C (cognitive status) - brief interview for mental status dated 01/30/24 documents a score of fifteen which indicates cognitively intact. Section GG documents: 03- roll left and right - 03 indicated partial/moderate assistance- helper does less than half the effort. Helper lifts, hold or supports truck or limbs but provides less than half the effort, (functional abilities and goals/functional limitation in range of motion) documents: 1 upper/lower extremity - 1 indicates dependent- helper complete all the activities for the resident. On 2/13/24 at 1:28pm, R3 who was assessed to be alert and orient to person, place and time stated, R3 said, V13 (cna) disconnected his call light from the wall. R3 stated, he fell due to reaching for his call light. On 2/13/24 3:04pm, V11 (nurse manager) stated, R3 was reaching for something and had a fall. V11 stated we spoke with V13 about R3's call light not being answered. On 2/13/24 at 3:38pm, V12 (guest relations) stated, R3 who was alert and oriented times three, stated, he R3 fell out of bed attempting to reach the call light. R3 has never made an allegation of falling out the bed before or the inability of reaching the call light. V12 stated, if R3 stated it happened then it did. After speaking with R3, V12 stated, she completed a concern form related to V13 not having the call light within reach. Concern/Compliment form dated 1/29/24 document: V12 took the report- R3 was educated on call light use. Staff made aware resident (R3) call light is within reach when rounding. R3's care plan initiated 1/26/24 documents: R3 was at risk for fall related to deconditioning and weakness r/t left hemiplegia, lumbar stenosis, and sciatica. Interventions: Keep call light and desired personal items within reach. Fall incident dated 1/29/24 documents: Alerted to residents (R3) room, resident sitting on buttock on the floor next to bed. Resident stated, I slid out of bed while attempting to turn over. Resident assisted back to bed with mechanical lift. Mental status: oriented to person, place, and situation. Predisposing physiological factors: gait imbalance and impaired memory. No witnessed found. Fall prevention program dated 11/28/12 documents: to assure the safety of all residents in the facility. At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times. Based on interview and record review, the facility failed to follow therapy recommendations, and fall prevention interventions to include use of a manual wheelchair and keeping the call light within reach. This affected two of three residents (R2, R3) reviewed for safe use of a motorized wheelchair and fall prevention interventions. This failure resulted in R2 using the motorized wheelchair resulting in a fall incident requiring R2 to be sent to the local hospital for treatment of a right frontal scalp hematoma. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of muscle wasting, history of falling, acute kidney failure, reduced mobility, weakness, fracture of right pubis, right artificial hip joint, osteoarthritis, and dysphagia. R2's fall report dated 1/13/24 documents: The nurse heard a loud noise in the resident's room. The nurse witnessed resident on the right side near the foot of his bed and appeared to have fallen from electric wheelchair. Under resident description: Resident stated he was attempting to move his power chair and fell. Under injury abrasion to top of scalp and laceration to left hand. Under mental status oriented to person only. Under predisposing environmental factors document equipment or device. On 1/14/23 fall root cause documents: Resident stated he was sitting up in his motorized wheelchair when he was attempting to move his chair and fell out after leaning too far. On 2/13/24 at 1:17pm, V5 (therapy director) stated when R2 was participating in therapy. R2 had a motorized wheelchair he had used in the past for mobility. At time of therapy the use of the motorized wheelchair was not attempted due to medical concern related to cognition and functional ability. R2 had poor sitting balance and required a mechanical lift for transfers which would contradict the use of a motorized scooter. R2 was utilizing a manual wheelchair during therapy. When there are any changes to a resident's assistance devices, therapy would inform the unit supervisor of the changes. R2's motorized wheelchair should have been removed by staff to ensure R2 did not use it. V5 stated the therapy department did not remove R2's chair and was unsure if it was still in R2's room after discharge from therapy. R2 should have been utilizing a manual wheelchair. On 2/15/24 at 4:00PM, V17(CNA) was the assigned aide to R2 at time of fall on 1/13/24. V17 stated she recalls R2 being in his motorized wheelchair at start of her shift in common area. A little later, R2 was on the floor in his room on the mat. V17 was unable to recall any other details of fall. V17 stated she was not sure if R2 fell from the motorized wheelchair or if the motorized wheelchair was in the room at time of fall. V17 stated she does not think she assisted R2 with going back into the bed after her shift prior to the fall. V17 does not recall anyone saying R2 could not use the motorized wheelchair. On 2/13/24 at 2:40PM, V9 assistant director of nursing (ADON/third floor supervisor) stated if there were changes in resident's assistive devices use or mobility, therapy would communicate with me or at stand-up meeting in the morning. V9 does not recall ever being told that R2 could not use the motorized wheelchair. If it was communicated that R2 could not use the device, it would be removed from the room. R2's therapy notes dated 12/16/23 documents under initial assessment wheelchair mobility: wheel fifty feet with two turns- not attempted due to medical conditions or safety concerns; type of wheelchair or scooter used - motorized; wheel one hundred fifty feet- not attempted due to medical conditions or safety concerns. Under balance: Patient sits unsupported for thirty seconds with feet flat on floor and no back support- No; amount assisted needed to sit at edge of bed- moderate assistance; time patient can sit unsupported- unable seconds. Under reason for therapy clinical impressions: Based upon examination of patient's body regions, systems and structures, patient presents with strength impairments, safety awareness deficits, balance deficits and muscle disuse and in consideration of history, personal factors and functional abilities documented in this evaluation summary. Patient requires skilled therapy. Physical therapy Discharge summary dated [DATE] documents under wheelchair mobility patient will increase ability to safely propel in wheelchair one hundred fifty feet with supervision or touching assistance on level surfaces. At discharge required partial to moderate assistance. Under wheelchair mobility type of wheelchair manual. R2's hospital record dated 1/13/24 documents CT/computed tomography scan of head impression: no acute traumatic injury in brain or spine. No acute intracranial hemorrhage. Small right frontal scalp hematoma without underlying calvarial fracture.

Based on interview and record review, the facility failed to follow the physician's orders for one resident with a diagnosis of osteoarthritis by not applying a prescribed lidocaine pain patch (local anesthetic) as ordered. This affected one of three residents (R3) reviewed for pain. This failure resulted in R3 complaining and enduring left knee pain with a pain score of ten out of ten for over seven hours (zero equals no pain, five equals moderate pain, and ten equal excruciating pain). Findings Include: R3 brief interview for mental status dated 01/30/24 documents a score of fifteen which indicates cognitively intact. R3's physician order summary start date 2/8/2024 documents: Lidocaine external Patch 4% (lidocaine) -Apply to left knee and low back topically one time a day for mild pain and removed per schedule. Physician progress note dated 2/12/24 documents: R3 has a diagnosis of Osteoarthritis (OA) and left knee arthroscopy. On 2/13/24 at 1:28pm, R3 who was assessed to be alert and orient to person, time and place stated, he did not get his pain patch applied to his left knee this morning. R3 stated, his pain was a 10 out of 10. R3 stated, the pain patch did not come off because it was not applied. R3 was observed in bed while V33 (cna) and V34 (cna) provided ADL/activities of daily living care. R3 was observed without a pain patch on his left knee, no patch was observed stuck to the inside of R3's pajama or on R3's bed pad/sheets. V33 (cna) and V34 (cna) both stated, R3 did not have a pain patch on his left knee nor was the patch on R3's clothing or bed/bedding. V34 said, she provided care to R3 all day. R3 did not have a patch on his left knee this morning. On 2/13/24 3:04pm, V11 (nurse manager) stated, the nurse should have applied R3's pain patch. V11 stated, she would expect physician orders to be followed. On 2/21/24 at 2:37PM, V32 (nurse), stated, she applies R3's pain patch to his lower back and knee every time she works. The administration of R3's pain patch will be recorded on the medication administration record and on the location administration report. Location of Administration report dated 2/13/24 documents: V32 (nurse) administered, topically to back -lower, mid/ thoracic (left) Pain Management Policy dated 11/28/12 documents: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, the facility failed to implement effective fall prevention interventions and determine the root cause of previous falls to prevent and/or reduce the risk of residents falling. This affected three of three residents (R6, R4, and R8) reviewed for fall prevention interventions. This failure resulted in R6 falling from bed while staff was providing direct care and leaving resident unmonitored returning to find R6 on the floor. R6 was sent to the hospital assessed to have sustained a bilateral subarachnoid hemorrhage. The findings include: 1.R6 is [AGE] years old with diagnoses including but not limited to End Stage Renal Dialysis, Weakness, Diabetes, Epilepsy, Encounter for Palliative Care. R6 cognitive assessment dated [DATE] indicates a score of 11 and no behaviors were reported. On 12/20/23 at 9:45AM V11, Certified Nursing Assistant (CNA), said on 10/11/23 I was giving R6 a bed bath. V11 said I left the room to get a pillowcase and sheet. V11 said when I returned to the room R6 was on the floor. V11 said during her bath R6 was a little agitated. V11 said R6 had a history of throwing her legs out the bed. V11 said I saw R6 kick her leg out before I left the room and I put it back in the bed. V11 said when R6 was on the floor she was on her right side, in between the two beds. V11 said later I was told by other staff that R6 has a behavior of throwing herself out of bed. V11 said R6 was not on a floor mat, the mat was on the other side of the bed. V11 said R6 did not land on the mat. V11 said R6 had a knot developing on her head after the fall. V11 said I had never seen R6 stand up, R6 required total care and she was not able to stand up. V11 said R6 had to roll out, if she kicked her leg out. On 12/20/23 at 12:27PM V17 said the Restorative Observation is done to get an understanding of what kind of Activity of Daily Living care the resident needs. V17 said the Restorative Observation can be used to develop the care plan. V17 said a resident's bed mobility ability can change. V17 said the staff will know how to provide care for a resident by the preceding staff communicating with the oncoming staff. V17 said R6's care plan should include her need for assistance with bed mobility. The surveyor and V17 reviewed R6's care plan. V17 said bed mobility is not on there. V17 said any information on the care plan designated with the letter K will carry to the CNA [NAME] and the CNA can see the resident care needs. On 12/20/23 at 2:10PM V21, MDS Nurse, said it is important to know a resident's functional status. V21 said it is important for staff to know how much assistance is required for a functional task. V21 was asked if as nurses we still consider Bed Mobility an activity of daily living, V21 replied, yes. On 12/20/23 at 2:49PM V3, Director of Nursing, said if a resident falls and suffers a head injury then floor mats were not an effective intervention for that person. On 12/21/23 at 10:17PM V24, Doctor, said a subarachnoid hemorrhage can be caused by trauma. V24 said R6's subarachnoid hemorrhage was likely caused by trauma. R6's Restorative Observation dated 9/12/23 documents observation of bed mobility is total dependency with two plus person's physical assist. R6 believes she is capable of increasing independence. R6's Fall Scale dated 9/12/23 indicates a score of 16, low risk. R6's fall scale dated 10/1/23 indicates a score of 31, moderate risk. Risk factors include diagnosis and R6 overestimates or forgets limits. R6's Functional Status dated 9/29/23 documents the use of one person with total dependency for bed mobility. Range of Motion Limitations include impairments to upper and lower extremities on both sides. R6's incident report dated 10/1/23 documents R6 on the floor. No cause of R6's fall was documented or provided. A summary of R6's 10/1/23 fall was provided documenting her diagnosis, orientations, and that R6 was unable to say what happened. Bed position and ability to move her own extremity is documented. No cause or circumstance causing or related to the fall was provided. R6's incident report dated 10/11/23 documents R6 on the floor with hematoma noted to the right forehead. Incident report submitted to The State Agency does not include why or cause to R6's fall. Statements in investigation include V19, Registered Nurse. Attempts to contact V19 during the survey were unsuccessful and V19 is no longer employed at the facility. V11, CNA, statement says she did not witness the fall. Care plan reviewed for R6 no bed mobility assistance listed despite self-care deficit related to hemiplegia and limited mobility. R6's hospital record CT Head dated 10/11/23 Final Result Impression: Scattered bilateral subarachnoid hemorrhages most prominent along the right MCA cistern and the right Sylvian Fissure. Subarachnoid hemorrhages (pleural) along the high left parietal lobe and posterior right temporal region also noted. Emergency Department Course notes R6 admit for further monitoring and possible hospice transition. 2. R4 is [AGE] years old with diagnoses including, but not limited to Cerebral Palsy, Atrial Fibrillation, Vascular Dementia, Autistic Disorder, Schizophrenia, Bipolar Disorder, Generalized Anxiety, and Schizoaffective. Cognitive assessment dated [DATE] indicates a score of 13. On 12/15/23 at 1:10PM V10, Licensed Practical Nurse (LPN), said on 11/12/23 I stepped into R4's room and she was sitting on the floor. V10 said this is a behavior for R4. V10 said I have never seen R4 actually put herself on the floor, but I am told this is a behavior for her. On 12/15/23 at 2:14PM V9, LPN, said R4 throws herself out of the wheelchair or bed onto the floor. On 12/19/23 at 10:48AM V2, Certified Nursing Assistant (CNA), said when things don't go R4's way, she puts herself on the floor. On 12/19/23 at 2:19PM the surveyor looked inside R4's room. R4 was not in the room and no floor mats were observed on the floor, along the walls, or inside the room. On 12/20/23 at 8:56AM the surveyor observed R4 in her bed, the bed was positioned higher than the roommate's bed, and one floor mat was observed placed between R4's bed and the roommate's bed. R4's bed is not up against a wall or surface in which a floor mat cannot be placed. V18, CNA, walked into R4's room and said she is the assigned CNA for the room. V18 showed the surveyor R4's wheelchair and lifted the seat/cushion. No skid pad was observed on the wheelchair seat. V18 said there is 1 floor mat in the room for R4's roommate, R12. R12 quickly said that's for her (indicated R4). V18 demonstrated R4's bed lowers more, nearly to the floor. V18 said no one reported to me that R4 has behaviors. V18 was asked what safety interventions are in place for R4. V18 said she could check the computer. V18 was unable to find the information and asked V22, Assistant Director of Nursing, who then called V17, Restorative Nurse, who assisted. V17 had to click multiple sites in R4's electronic record before the information for bilateral floor mats and nonskid pad were located for R4. The surveyor asked V18 if she was aware that R4 required bilateral floor mats and a nonskid pad in her wheelchair. V18 said not until now. V18 said she would not have known where to locate the nonskid pad for R4. V17 entered R4's room with the surveyor and observed only 1 floor mat, not bilateral mats for R4. V17 said someone must have taken the other mat out of the room. V17 said the restorative office has nonskid pads available for the residents. V17 said staff may have removed the nonskid pad prior if it was soiled when the surveyor reported it had not been present when V18 checked with the surveyor. R4's care plan documents she is alert and oriented times two with periods of confusion. R4 has behaviors of throwing herself on the floor and intentionally slides out of her wheelchair. R4 has floor mats (pleural), nonskid device on wheelchair and keep floor mats in place while resident in bed. 3.R8 is [AGE] years old with diagnosis including but not limited to Dementia, Repeated Falls, Hypertension, Difficulty in Walking, Transient Ischemic Attack and Cerebral Infarction. On 12/19/23 from 11:25AM thru 11:42AM R8 was observed sitting in her wheelchair. R8 was moved throughout the unit during the time from the nurses' station to the dining room with staff assistance. R8 observed to be wearing pink fuzzy socks and no shoes or slippers and the socks had no nonskid on them. R8 is documented on the Fall Incidents list with falls on 10/21/23; 10/30/23; 11/3/23 and 12/5/23. R8's incident report dated 10/21/23at 9:16PM states R8 seen on the floor and R8 stated I am trying to get out of the bed, and I fell. The fall care plan intervention states R8 should be up in wheelchair in a supervised area when awake at night. No follow up notes related to the fall investigation was provided to the surveyor. There is no documented cause of R8's fall. R8's incident report dated 10/30/23 at 9:16PM (same time as prior fall) states R8 observed sitting on the floor next to her bed. There are no follow up notes related to the fall investigation was provided to the surveyor. There is no documented cause of R8's fall. There is no added intervention to the fall care plan. R8 fell on [DATE], 3 days after her last fall. R8's care plan dated 5/16/23 for functional deficit in ambulation states ensure R8 is wearing proper footwear. On 12/19/23 the surveyor requested the documented Root Cause Analysis or investigations that show the fall root cause for R4 and R6 from V4, Administrator. V4 said V3 is the fall nurse. On 12/20/23 before interview with V4 at 10:15AM, the surveyor requested the information for the root causes analysis for R4 and R6 falls. By the end of day on 12/20/23 no root cause analysis documentation or investigations were provided to the surveyor. On 12/20/23 at 1:44PM V3, Director of Nursing, said I have been in this position since last Monday or Tuesday (12/11/23 or 12/12/23.) V3 said I have not been told I am the fall coordinator. V3 said the purpose of a root cause analysis is to find a way to prevent another fall and to develop interventions. V3 said I am not in charge of falls. The facility Fall Prevention Program dated 11/21/17 states the program includes the following: immediate change in interventions that were successful. The care plan incorporates addresses each fall. Falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safe interventions. Interventions include direct care staff will be oriented and trained in the fall program. Footwear will be monitored to ensure the resident has proper fitting shoes or nonskid footwear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent or determine how an injury of unknown origin to the left femur for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining an injury to the left femur with the bone exposed through the left thigh wound causing the resident to be sent to the local hospital for treatment. Findings Include: R1 is a [AGE] year-old with the following diagnoses: functional quadriplegia and osteomyelitis of the sacral region. R1 was admitted to the facility on [DATE]. A Nursing note dated 11/7/23 documents the floor nurse (V8) was informed by the wound care nurse (V4) that R1's left thigh wound was bleeding. Upon observation, R1 was awake and in no distress. Bleeding was observed to the left thigh wound. The wound care nurse applied pressure to the site. While the nurse was reviewing R1's chart at the nurse's station, the DON informed the nurse that R1 needed to go out to the hospital via 911 due the wound bleeding and bone protrusion. The paramedics arrived in the facility and transferred R1 to the hospital. A Wound Care note dated 11/7/23 documents while doing R1's daily treatments to the left ischium and sacral wounds, R1 was repositioned on R1's back. At this time, the wound tech (V9) and the wound care nurse (V4) noticed blood along with a blood clot on R1's pad. Blood was coming from the left thigh wound. Another wound care nurse (V10) was called from another room to help assess R1. The floor nurse (V8) was notified, and pressure was applied to the wound with gauze and an ABD pad. The DON was notified. When the wound care nurse removed the gauze, bone was protruding from R1's thigh. 911 was called. The wound was covered with a dressing until the paramedics arrived and took over. The Fire Department Record dated 11/7/23 documents the crew was dispatched to the facility for a medical emergency. According to the wound care nurses on scene, R1's left femur is broken, and the bone is protruding out of the leg. The wound care nurse also mentioned R1's wound is an old wound, but the break in the femur is new. R1's leg was already wrapped up and cleansed prior to arrival. The wound care nurse also stated the old bandages were filled with blood. R1 was found alert and oriented times one in bed. A deformity was noted to the left upper leg. R1 was given 50 micrograms of fentanyl pain medication through an IV while in route. R1's level of distress is documented as moderate. R1 was transferred to the hospital without incident. The Hospital Records dated 11/7/23 documents orthopedic surgery was consulted for a broken femur on R1. The orthopedic surgery note documents staff at the nursing home was treating R1 for chronic appearing wounds on the left side. While the dressing change was performed today, they noted that bone was protruding from the wound on the left thigh. There was no known history of trauma. There is an obvious type three open left femur fracture with a chronic appearing wound. The left lower extremity has an obvious deformity. There is a large, open, chronic appearing wound measuring approximately 10 cm across its greatest diameter to the anterior medial, mid-thigh with protruding proximal femoral bone. There was slow losing blood from the wound. Given the history of the appearance of the wound, it is likely that the femur fracture is chronic, and the flexion deformity of the proximal fragment has been gradually degrading the skin with full thickness perforation through the skin earlier today at the nursing home. Reduction attempts were unsuccessful in the emergency department for realigning the femur. This is likely contributed due to the chronicity of the injury. X-ray of the femur was completed on this day and shows there is an oblique fracture through the junction of the middle third of the femur. Bone fragments are completely displaced an overriding. There is no identifiable destructive bone lesion to indicate pathological fracture. The Facility Serious Injury Incident and Communicable Disease Report dated 11/8/23 documents R1 is alert and oriented times zero and nonverbal with a history of multiple wounds. During wound care, R1 was noted with bleeding to the left leg wound site. Upon further assessment, nurses noted visible bone at the wound site. The wound was wrapped to control bleeding. R1 had no visual cues of pain or distress. 911 was called. On 11/9/23 at 10:19AM, V2 (Paramedic) stated the paramedics were called to the facility due to R1 having a bone sticking out of a wound on the left leg and the wound was bleeding. V2 endorsed facility staff was not able to say how the fracture occurred and R1 was not able to say what happened either since R1 was nonverbal. V2 reported a wound care nurse told V2 they were doing the dressing changes and when R1 was turned back on the bed the bone came out of R1's leg. V2 stated the femur is the strongest bone in the body and open fractures like the one R1 had happen from high impact. On 11/9/23 at 12:06PM, V3 (CNA) stated V3 changed R1 around 11AM and there was no bleeding noted at that time. V3 endorsed R1 is nonverbal, has contracted legs, and can't move independently. On 11/9/23 at 12:17PM, V4 (Wound Care Nurse) stated V4 was changing the wound dressings on R1's back side and had R1 rolled on R1's right side. When the wound tech rolled R1 on to R1's back to be turned to the other side, blood was noticed on the pad underneath R1 with a blood clot. V4 endorsed getting V10 (Wound Care Nurse) to help with the situation. V4 and V10 notified appropriate staff and applied pressure to the wound. V4 endorsed since R1 was actively bleeding then 911 was called for R1 to be evaluated at the hospital. V4 stated before the paramedics arrived V4 was cleaning the wound and noticed bone was sticking out of the wound once all the gauze was removed. V4 stated it was about an inch of bone sticking out of the leg. V4 denied noticing a deformity to R1's left leg. V4 reported R1 is nonverbal, and no one knows how the fracture occurred. On 11/9/23 at 12:42PM, V9 (Wound Care Tech) stated V9 was assisting V4 change R1's dressing and rolled R1 to the side while V4 changed the wounds on the back. V9 endorsed when R1 was rolled onto the back to go to the other side, they noticed blood was on the pad underneath R1 and blood was found coming from the left thigh wound. V9 stated bone was found sticking out of the left thigh wound about one or two inches while V4 was cleaning the wound. V9 denied being aware how R1 fractured the left leg. V9 stated R1 is nonverbal at baseline and not able to say how the fracture occurred. V9 denied knowing what an injury of unknown origin is. On 11/9/23 at 12:55PM, V10 (Wound Care Nurse) stated V10 was called to R1's room by V4. V10 endorsed R1 was bleeding from the left thigh wound and when staff was cleaning the wound, a piece of bone was sticking out of the wound about one inch long. V10 reported this would be considered an injury of unknown origin because R1 is not able to say what happened and neither can staff. On 11/9/23 at 1:31PM, V8 (Nurse) stated R1 was getting wound treatment completed by V4 when V8 was notified that R1 was bleeding from the left thigh wound. V8 reported V4 or V10 saw bone coming out of R1's leg so 911 was called to take R1 to the hospital. V8 defined an injury of unknown origin as when people can't talk to tell you what happened and no one else knows what happened. Based on this definition from V8, V8 was not able to say if R1's injury would be considered an injury of unknown origin. On 11/9/23 at 3:27PM, V1 (DON) stated V1 was notified R1 was bleeding from the left leg wound and told V4 to send R1 to the hospital for active bleeding. V1 endorsed when staff was cleaning the wound before the paramedics arrived, they noticed a white piece sticking out of the wound. V1 reported V4 and V10 thought it was a piece of gauze but realized it was bone when they tried to take it out. V1 stated this is an injury of unknown origin because R1 was not able to say how the fracture occurred and staff is not sure how the fracture occurred. On 11/14/23 at 10:39AM, V12 (Hospital Orthopedic Surgeon) stated R1 had an open fracture to the middle of the left femur. V12 endorsed this fracture is chronic meaning it is between three to six weeks old. V12 reported the wound to the left thigh is due to the bone causing pressure to the skin breaking it open. V12 stated this fracture is a type III fracture which means the wound caused by the exposed bone is larger than 10 centimeters. V12 stated there is an obvious deformity to the left thigh meaning the thigh looked like it was on an angle. V12 endorsed nursing staff should have noticed the deformity to the left before the bone came through the skin. V12 denied this being a pathological fracture, from osteomyelitis, or being caused by R1's leg contractures. V12 stated this kind of fracture is due to some kind of impact to the bone. The last hospitalization for R1 was on 8/4/23. The Hospital Records dated 8/4/23 document R1 was admitted to the hospital for a sacral ulcer infection. There is no deformity of the left leg documented on this hospitalization. The Restorative Contracture Observation date of 10/5/23 documents R1 has limitation and range of motion. R1 has moderate contractures of the left hip and knee. R1 is bedbound, paralyzed, and unable to initiate movement independently. The Minimum Data Set (MDS) dated [DATE] documents R1 does not have a score for the Brief Interview for Mental Status due to R1 rarely/never being understood. Section GG of the MDS documents R1 is dependent in all care areas. R1 is not able to attempt any bed mobility or transfers. Section I of the MDS documents R1 does not have any fractures and does not have any bone diseases other than osteomyelitis of the sacral region. The care plan was reviewed and there is no documentation regarding R1 having weak bones or any bone diseases that would easily cause a fracture. The policy titled, Abuse Prevention and Reporting- Illinois, dated 10/24/22 documents, .Injuries of Unknown Source: . and injury should be classified as an injury of unknown source, when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury, could not be explained by the resident; and the injury is suspicious, because of the extent of the injury or the location of the injury (e.g., the injury is located in an area, not generally vulnerable to trauma) or the number of injuries, observed at one particular point in time or the incidence of injuries overtime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to order and provide wound care treatments for a left thigh wound for nine days after the wound was discovered for one (R1) out the three residents reviewed for wound care treatments in a total sample of three. This failure resulted in the left thigh wound increasing in size from 6.5cm x 5.5cm x 4cm to 9cm x 4cm x 4cm within seven days. Findings Include: R1 is a [AGE] year-old with the following diagnoses: functional quadriplegia and osteomyelitis of the sacral region. R1 was admitted to the facility on [DATE]. The Wound Assessment Details Report dated 10/16/23 documents the left front thigh wound was identified on this day. It is documented as unstageable. The wound measures 6.5 cm x 5.5 cm by unknown. There is no documentation of what kind of dressing was applied to the wound. The Wound Assessment Details report dated 10/24/23 documents the left front thigh wound is still unstageable and measures 6 cm x 5 cm x 4 cm. There is no documentation of what kind of dressing was applied to the wound. The Wound Assessment Details Report dated 10/31/23 documents the left front thigh wound is still unstageable and has declined. The wound is now 9 cm x 4 cm x 4 cm. The Wound Nurse Practitioner note dated 10/19/23 documents R1 developed a new pressure injury to the left thigh region. It is unstageable and measure 7cm x 5cm x 0.4cm with a moderate amount of serosanguineous drainage. This wound is documented as needing to be cleansed with normal saline with silver alginate applied and a border gauze to cover the wound. No order was put in the TAR for this wound on this date. The Wound Nurse Practitioner note dated 11/2/23 documents the left thigh wound is an unstageable pressure injury that measures 9 cm x 4 cm x 4 cm. The wound has declined by getting larger in size. The wound has a moderate amount of serosanguinous drainage with a mild odor. The wound bed has 90% bright red granulation tissue with 10% slough. On 11/9/23 at 12:17PM, V4 (Wound Care Nurse) stated the wound to the left thigh is a stage four pressure ulcer because it is down to the bone. V4 was unsure of the exact date but reported the wound developed about one month ago. V4 stated the left thigh wound has deteriorated by getting larger in size and having more slough tissue. On 11/9/23 at 2:51PM, V11 (Wound Nurse Practitioner) stated the first order placed for the left thigh wound was silver alginate and to be covered by a dressing after cleansing. V11 endorsed silver alginate is used as an antimicrobial agent and helps with absorption of drainage. V11 reported seeing R1 on 10/26/23 and changing the treatment order to Dakin's solution which is a stronger antimicrobial treatment. V1 endorsed changing the wound treatment to this because the wound was larger in size, had a mild odor, and had more slough tissue. V11 endorsed while completing rounds a wound care nurse from the facility rounds with V11 and enters the orders into the computer system after V11 verbally tells the nurse the order. V11 stated if a dressing is not completed on an open wound, then the wound can have a decline, or an infection can develop. On 11/9/23 at 3:05PM, V10 (Wound Care Nurse) stated V11 comes around weekly to round on the residents and put in any new orders as they are rounding together. V10 reported all orders made by V11 should be put in the computer otherwise staff will not know what treatments to complete. V10 endorsed if no treatments are completed on a wound then the wound can become worse or infected. V10 stated R1's left thigh wound did get worse by getting larger in size. V10 endorsed if an order is not in the computer system, then the physician should be contacted as soon as possible for an order. On 11/9/23 at 3:27PM, V1 (DON) stated a wound nurse rounds with V11 while V11 is in the building and enters in the new wound treatment orders. V1 endorsed the new orders should be put in the system immediately. V1 stated wound care dressings are not done as ordered then a wound could deteriorate. V1 endorsed if V11 verbalized the order then it should be put into the computer system where it is generated in the Treatment Administration Record/TAR so staff know how to treat the wound. When asked what does it mean if there is no documentation for wound care treatments being completed, V1 stated, If it's not charted, then it is considered not done. That's not our policy. That's a nursing policy. The Physician Order Sheet documents wound care treatment orders for the left thigh wound were placed on 10/25/23. There are no documented orders for wound care treatments for the left thigh site before this date. The Treatment Administration Record dated 10/2023 documents the first treatment for the left thigh wound was completed on 10/25/23 on the day the treatment was ordered. There are no other completed treatments documented on this wound site before 10/25/23. The Care Plan dated 10/26/23 documents R1 has active skin issues and remains at high risk for further skin breakdown related to immobility, incontinence, total assist in care status, and osteomyelitis. One of the interventions for this care plan is documented to apply treatments as ordered. The policy titled, Pressure Injury and Skin Condition Assessment, dated 1/17/18 documents, 18. Physician order treatments shall be initialed by the staff on the electronic treatment administration record after each administration. Other nursing measures not involving medication shall be documented in the weekly wound assessment or nurse's notes. The policy titled, Physician Orders- Entering and Processing, dated 1/31/18 documents, Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders .5. Following a physician visit, a licensed nurse will check for any orders that require confirmation on your clinical> orders> pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed. 6. Verbal and telephone orders will be documented as such in the electronic medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly insert a urinary catheter and inflated the catheter balloon in the resident's (R1) urethra during the insertion for one out of three residents reviewed for catheter care in a total sample of six. This failure caused R1 to be hospitalized for a traumatic urinary catheter insertion where blood collected in the urinary catheter bag, a urinary tract infection, and urinary retention. Findings Include: R1 is a [AGE] year-old with the following diagnosis: diffuse traumatic brain injury, encounter for tracheostomy and gastrostomy, and neuromuscular dysfunction of the bladder. R1 admitted to the facility on [DATE] and discharged on 9/23/23. R1's EMR- Medication Administration note dated 9/22/23 documents a new urinary catheter was reinserted due to leakage of the old urinary catheter. 100 ML of clear urine was noted. R1's Nursing note dated 9/23/23 at 1:44 PM documents R1 complained of pain from getting a urinary catheter reinserted yesterday. Blood was coming from the genital area. R1's Nursing note dated 9/23/23 at 3:32 PM documents R1 had a heart rate of 165 bpm and stomach was distended. There was no urine return into the urinary catheter bag. A new urinary catheter was reinserted, but still no urine collected into the bag. The Hospital Records dated 9/23/23 document R1 was sent to the hospital with tachycardia and appeared to be septic. R1 was initially hypotensive with blood pressures in the 80s but responded well to fluids. R1 was found to have a urinary tract infection and needed to be sent to the intensive care unit due to not being able to maintain blood pressure. A CT (computerized tomography) scan of the R1's abdomen was requested because of apparent distention. The CT of the abdomen and pelvis was completed on 9/24/23 at 1:36 AM and showed the urinary catheter balloon was located in R1's penile urethra. The Laboratory Levels dated 9/23/23 at 4:06 PM document the blood urea nitrogen level as 57 mg/dL (normal is 5-28 mg/dL) and creatinine as 1.3 mg/dL (normal is 0.74-1.2 mg/dL). R1 had a diagnosis of acute kidney injury in the intensive care unit likely to pre-and postrenal in the setting of shock and obstructive uropathy. There was a traumatic urinary catheter insertion at the nursing home. Urology was consulted. A Urology note dated 9/24/23 at 6:51 AM documents R1 had urinary retention with urethral trauma. The urinary catheter was found to be in the urethra. Hospital nursing staff was unable to successfully replace the urinary catheter. The urologist was called to insert a different type of urinary catheter. With some effort, the urinary catheter was able to be placed. 1100 mL of urine drained immediately upon the new catheter being placed. On 10/5/23 at 1:45PM, R1 stated the urinary catheter started leaking the day before going to the hospital so a new one was placed but after that I had pain in the catheter area that I did not have before. R1 endorsed the next day the catheter started bleeding and was more painful. R1 endorsed being sent to the hospital the next day due to not being able to urinate and the urinary catheter only collecting blood. R1 endorsed having a procedure done while at the hospital so a new catheter could be put in. On 10/5/23 at 1:00PM, V3 (Nurse) stated the CNA notified V3 there was bright red blood in R1's urinary catheter bag. V3 endorsed taking that catheter out and putting in a new catheter. V3 reported putting a new catheter in place but state no urine would collect in the bag. V3 stated irrigating the catheter but only got bright red blood back for return. V3 stated R1's stomach looked bigger also. On 10/5/23 at 2:56 PM, V7 (CNA) stated the day before going to the hospital V9 replaced R1's urinary catheter due to leaking. V7 denied emptying any urine from the bag before leaving for the day but endorsed it was inserted an hour before V7 left. V7 reported staff check for bleeding after a urinary catheter insertion to monitor the resident. On 10/5/23 at 3:33pm, V2 (DON) stated R1 had a difficult urinary catheter insertion and blood was in the catheter tubing. V2 reported the nurse practitioner was notified and sent R1 out to the hospital for an evaluation. V2 endorsed staff need to monitor for urinary output, a distended stomach, bleeding, and pain after a urinary catheter insertion. V2 reported if there is no urine collecting in the bag within 4-6 hours then there is an issue with the catheter. On 10/5/23 at 3:48PM, V8 (CNA) stated R1 was having problems with a leaking catheter so V3 changed the catheter but when V8 returned to the room after lunch the tubing was filled with blood during repositioning. V8 reported emptying about 500 mL of only blood from the bag. V8 reported blood was also coming from R1's genital area. On 10/5/23 at 4:02PM, V9 (Nurse) stated V9 changed the urinary catheter on 9/22/23 due to R1 having urine leak from R1's genital area. V9 stated, You insert the tube until you feel like you're far enough back. After that you insert the water to inflate the balloon. V9 stated you want to make sure that you have at least a little bit of yellow urine in the tube coming out to make sure that you're actually in the bladder. V9 reported urinary output and bleeding need to be monitored after insertion. V9 stated, You get everything set up and then you clean the head of the p****. You insert the tube until you feel like you're far enough back. After that you insert the water to inflate the balloon. Do you want to make sure that you have at least a little bit of yellow urine in the tube coming out to make sure that you're actually in the bladder. On 10/5/23 at 4:38PM, V10 (Nurse) stated V10 was not made aware R1 had a new urinary catheter but should have been told so it could have been monitored more closely. On 10/6/23 at 3:14PM, V12 (Nurse Practitioner stated nursing staff notified V12 about the amount of blood in R1's urinary catheter bag. V12 reported when assessing R1 after the catheter was attempted to be put in a second time only blood was coming out of the tubing even after irrigation. V12 endorsed urinary output should be monitored after place a new catheter to make sure the kidneys are functioning properly. V12 endorsed a physician should be notified for a difficult catheter insertion in case the resident needs to be sent out to the urologist. On 10/6/23 at 3:49PM, V13 (Primary Physician) stated the only thing that needs to be monitored after a urinary catheter insertion is that urine is collecting. V13 reported urine needs to be collecting at a minimum of 15 mL an hour to be considered normal kidney function. V13 endorsed people should make one to two liters of urine a day. V13 denied being aware of any difficulties putting in the catheter and reported a physician should be notified of difficult insertion to assist with placement. V13 stated inflating a urinary catheter balloon inside the urethra can cause direct trauma from the amount of pressure. R1's Care Plan dated 4/10/23 documents R1 has the following conditions requiring continued use of an indwelling catheter: stage four pressure ulcer with urine impeding healing. Interventions include assess for complication of catheter, position tubing to facilitate flow, observe for signs and symptoms of urinary tract infection, and notify the physician of any changes. R1's Physician Order Summary documents there was an order placed on 4/14/23 to change the indwelling urinary catheter for leakage, blockage, or accidental removal. The urinary catheter should be monitored every shift. An order on 6/19/23 documents every shift should record the total output of the urinary catheter. R1's Medication Administration Record dated 09/2023 documents an indwelling urinary catheter was changed on 09/22/23 at 3:30 PM. The output for the urinary catheter on 09/22/23 is documented three times a day. The dayshift is documented as an output of zero mL, there is no documentation for the evening shift, and there is an output of 550 mL for the night shift. The output for the urinary catheter on 09/23/23 is documented one time before R1 went to the hospital on the dayshift as zero mL. The Laboratory Report dated 7/28/23 documents the blood urea nitrogen level and creatinine level are within normal limits. There is no documentation that R1 had any issues with kidney function while at the facility. A policy on urinary catheter insertion and urinary catheter care/monitoring requested during this investigation. Per V1 (Administrator), the facility does not have any policies on urinary catheter insertion or care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed the facility failed to develop and implement a plan of care with interventions to reduce and/or prevent the risk of falling to include supervision and monitoring. This affected four of four residents (R1, R10, R19, and R20) reviewed for fall prevention interventions. This failure resulted in R1 not being supervised or monitored by staff resulting in a fall incident sustaining an acute fracture of the anterior and posterior wall of the left frontal sinus, and R10 being left unassisted by facility staff resulting in a fall incident sustaining a right femoral neck fracture. Findings include: 1.R1 is [AGE] years old with diagnosis including but not limited to Skull and Facial Bones Fracture, Traumatic Subdural and Subarachnoid Hemorrhage, History of Falling, Alcoholic Cirrhosis of Liver, and Psychoactive Substance Dependence. R1's cognitive patterns assessment dated [DATE] identifies him with a score of 12, moderately impaired. R1's fall scale evaluation dated 4/30/23 identifies him as a high risk for falling. a. Incident report for R1 dated 5/11/23 states nurse heard a noise and found R1 on the floor bleeding from his head. Nurse witness statement reads she was passing medications when she heard a loud noise. Per record R1 was hospitalized from [DATE] until 5/17/23. Hospital records dated 5/11/23 note CT of the head findings Left Frontal Scalp, Forehead and Left Periorbital Hematoma. Acute Fractures of The Anterior and Posterior Wall of The Left Frontal Sinus. b. On 7/26/23 at 12:26PM V21, Certified Nursing Assistant (CNA), said on 5/21/23 R1 kept getting up from his bed, he was trying to walk. V21 said R1 was put at the nurses' station and then he fell. V21 said she and the nurse heard a sound and then R1 was on the floor. V21 said I was at the nurses' station. V21 said I would have to walk across the nurses' station to get to R1 to prevent him from falling. V21 said I think the nurse was at a medication cart. V21 said neither I or the nurse were next to R1. On 7/26/23 at 1:33PM V24, Registered Nurse (RN), said on 5/21/23 R1 had been in bed and then he became restless. V24 said the CNA brought R1 to the nurses' station, he was sitting in front of the nurses' station, and then all of a sudden he fell forward. V24 said she did not see R1 fall but heard the sound. V24 said staff was sitting at the desk. V24 said no one was assigned to watch R1 at that time. V24 said the intervention to bring him to the nurses' station was not effective that night to prevent a fall. V24 said R1 sustained a laceration. R1's progress notes dated 5/21/23 at 1:58AM state he became restless and got out of bed. He was sitting at the nurses' station when he fell out of the chair. Laceration observed to right side of head with bleeding. R1's incident report dated 5/21/23 states R1 fell before staff could intervene. R1 hit his head. V21's witness statement states R1 was unsteady and trying to get up. R1 brought to nurses' station for closer monitoring. Heard a noise resident had fallen. V24's witness statement states R1 to be more closely monitored at the nurses' station. Statement reads V24 said she heard a noise and V24 observed R1 on his stomach. Per records R1 was hospitalized from [DATE] and readmitted on [DATE]. c. R1's incident report dated 5/27/23 states resident on floor. Witness statement of V38, CNA, states on 5/27/23 R1 was sitting in a wheelchair across from the nurses station while she was charting and heard a loud noise. R1 was on the floor. V37, LPN, witness statement states on 5/27/23 V37 was off the floor when R1 fell. R1's record indicated he was hospitalized on [DATE] and readmitted on [DATE]. d.R1's incident report dated 6/3/23 notes R1 on mats next to bed on buttocks. R1 sent to the hospital and readmitted on [DATE]. R1's records indicate he was hospitalized on [DATE] and readmitted to the facility on [DATE]. R1's progress notes dated 6/30/23 states R1 has poor safety awareness and declining. R1 impulsive to ambulate/transfer unassisted and R1 not realizing he needs assistance. When out of bed kept in common area within view. On 7/26/23 at 2:34PM V13, Director of Nursing, said R1 fell on 5/11/23. V13 said the nurse reported R1 was trying to get to the bathroom. V13 said the root cause of R1's fall was he was attempting to walk unassisted with a history of Ataxic Gait. V13 said after a therapy re-evaluation they said R1 should not be walking unassisted. V13 said the root cause of R1's fall on 5/21/23 was that he fell asleep in his chair and leaned forward. V13 said he nurse, and CNA were assigned to more closely monitor him. V13 said R1 is a high fall risk and needs to be monitored despite fall precautions used. V13 said R1 is unable to be redirected. V13 said we want R1 in an area where staff can see him at all times and the goal is to intervene. V13 said when R1 fell at the nurses' station he was sitting outside the station, not inside. V13 said since the fall on 5/11/23 R1 was not placed inside the nurses' station. Following his fall on 5/21/23 R1 sustained a laceration requiring 2 or 3 sutures. V13 said if you are not looking at the resident, then you are not monitoring. V13 said R1 had another fall on 5/27/23 and the reclining chair was not in place at that time, we didn't have a chance to put the chair in place. e. R1's progress notes dated 7/26/23 state he slid out of his chair at the nurses' station. On 7/26/23 at 4:12 PM the surveyor watched surveillance camera footage from 12:00PM - 1:33PM. V12, Administrator and V13 in the room. Footage started with resident sitting in reclining chair behind nurses' station, helmet on, legs under desk writing area. Staff at his side initially. Meal tray served to R1. At 1:07PM the staff observed feeding R1. At 1:16PM R1 feeding self, sitting alone at desk, no staff at the station near him. V12 said the person at desk with back to R1 is a third-party Nurse Practitioner (NP). Surveyor observed the NP is not able to see R1 with her back towards him. R1 noted to lean forward 30 to 45 degrees while sitting in the chair. At 1:22PM observed R1 sitting alone no staff looking at him. R1 pushed self-back from desk. Chair in upright position. R1 stood up, chair rolled approximately 2 feet back from him (per view on footage), R1 lost balance, fell back onto floor and onto his buttocks, and his helmet came off. Nurse from cart, outside of station assisted R1 back into chair. V13 said for R1's safety he is at the nurses' station so staff can monitor him. The current interventions are as effective as they can be. He has a tendency to lean forward, and he has a brain tumor. The surveyor asked V13 if the interventions are effective to prevent R1 from falling. V13 said we are doing as much as we can. R1's care plan initiated on 5/18/23 for safety denotes outcome to be R1 will remain safe. Risk for fall care plan initiated on 3/31/23 notes R1 will be free from injury related to falls. Intervention implemented on 6/18/23 denotes R1 to remain in common areas when out of bed, to be visible by staff. R1's fall care plan has no intervention following his fall on 5/21/23 to prevent the fall and injury on 5/27/23. Following the fall on 5/11/23 R1 was transferred to hospital for evaluation. The next intervention is dated 5/19/23 to have Physical Therapy re-evaluate R1. 2. R10 is [AGE] years old with diagnosis including but not limited to Fracture of Right Femur (6/21/23), Alzheimer's Disease, Dementia, Stiffness of Joint, Weakness, Delusional Disorders, Restlessness and agitation. R10's cognitive states dated 5/26/23 notes R10 is severely impaired with a score of 3. On 7/27/23 at 10:17AM V29, CNA, said I seen R10 going to the bathroom on 6/18/23. V29 said she it was normal for R10 to get up unassisted to use the bathroom. R10 said when I walked into the room to check on the roommate R10 was on the floor. V29 said R10 did not know how she fell. V29 said R10 said I think she may have slipped on the urine; the floor was wet. V29 said R10 had no bottoms on, her leggings and pull up were not up on R10. V29 said prior to that R10 was calm and sleeping. On 7/28/23 at 12:58PM V13, Director of Nursing, said a leaf on the doorway is a symbol that means the resident has been identified as a fall risk based on the fall risk assessment. V13 said a score of moderate to more risk includes the resident into the fall leaf program. V13 said if a resident falls, they are included in the fall risk program. V13 said the purpose of the program is so staff knows the resident is at risk. V13 said if there is a leaf on the door then staff needs to assist residents when seen standing or walking in the rooms. V13 said the resident may not need staff touch assist but they need staff to at least be present when they have a leaf on the doorway. R10's Fall Scale Evaluation dated 11/22/23 notes a score of 41, moderate risk is scored at 25-44. R10's fall report dated 6/18/23 notes R10 has impaired memory, incontinent and improper foot ware at the time of the fall. On 8/2/23 at 9:34AM V46, MDS Coordinator, said the purpose of the care plan is to provide a road map for care and provide guidelines to help up deliver care to the patient. V46 said the care plan is individualized and reflective of the needs of the patients. V46 said if a fall happens then the care plan would be updated. R10's Investigation Report dated 6/18/23 states at around 4:55AM R10 was observed sitting on the floor. R10 attempted to transfer and ambulate to the bathroom unassisted. R10 said I slipped and fell. X-Rays completed with findings of possible right neck femoral fracture. R10 transferred to the hospital for further evaluation. R10's care plan initiated on 6/22/23 notes R10 status post right femoral neck fracture status post fall. R10's care plan initiated on 5/31/23 states R10 is at risk for falls related to dementia, poor safety awareness, right femur fracture, history of falling, delusional disorder with agitation. Interventions include educate resident/caregivers about safety reminders and what to do if a fall occurs (5/31/23). Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility (5/31/23). These are the only fall interventions listed on the provided care plan prior to the fall on 6/18/23. 3. On 7/25/23 at 10:07AM the surveyor observed R19 self-ambulating out of the bathroom. A leaf is present on the doorway. R19's diagnosis include, but are not limited to, Seizures, Extrapyramidal and Movement Disorder, Tremors, and Unsteadiness on Feet. R19 Fall Scale Evaluation notes a score of 55, high risk is a score 45 and higher. 4. On 7/25/23 at 10:15AM R20 observed walking out of bathroom to the door entryway pushing his wheelchair and wearing a gait belt. No staff nearby. R20's diagnosis include, but are not limited to, Parkinson's Disease and Repeated Falls. R20 had a fall documented on 7/10/23. On 7/26/23 at 10:06AM V32, CNA, said the leaves on the doors mean the resident is on thin liquids. The surveyor asked V32 while clarifying and showing her the leaves on the door, which resemble an orange/red maple leaf, what these mean. V32 again said thin liquids. V32 said R20 can ambulate on his own, but he should be a 1 assist for standing. While speaking with V32 she said R19 needs supervision, like now he is just walking out of the bathroom. V32 remained in the hall with the surveyor and did not approach R19 or the room. V32 said R19 can go in and out the bathroom on his own. The facility Fall Prevention Policy date 11/21/17 states the program will include measures which determine the individuals needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision. Includes: use and implementation of professional standards of practice. Immediate change in interventions that were successful. Communication with staff members. Residents at risk of falling will be assisted with toileting needs. The facility Falling Leaf Program dated 11/28/12 states the team targets select residents who are at risk for falls. Criteria for the program includes impaired safety awareness that has contributed to a fall. Residents identified may have a leaf placed outside their door. The staff will visually check to ensure safety, assist with care needs, and prevent unsafe self-transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure that multiple sheets are not used on low air loss mattress, failed to follow treatment orders and interventions in preventing the worsening of pressure ulcer for one (R7) of three residents reviewed for pressure ulcers. This deficiency resulted in R7's pressure ulcer on the sacral region increasing in size and developing slough, necrotic tissue. Findings include: R7 is a [AGE] year-old female, initially admitted in the facility on 09/05/22 with diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Quadriplegia, Unspecified. R7's POS (Physician Order Sheets) documented the following: 4/10/23: Sacrum: Calcium Alginate with Silver as needed for wound care soilage or dislodgement 4/11/23: Sacrum: Calcium Alginate with Silver every day shift for wound care. Cleanse with NSS (normal saline solution), pat dry, apply Calcium alginate Ag, cover with dry dressing. Physician wound notes recorded the following measurements on R7's Stage 4 pressure ulcer on the sacral area: 02/03/23: 5 cm (centimeter) x 8 cm x 1.1 cm 03/02/23: 5.5 cm x 6 cm x 1.5 cm 03/09/23: 6.5 cm x 8 cm x 1.5 cm; History of Present Illness (HPI): Sacral wound size increased compared to the last visit. Surrounding skin was noted with excoriation. 03/16/23: 10 cm x 8.5 cm x 1.1 cm; HPI: Sacral wound debrided to remove devitalized tissue. 04/20/23: 8 cm x 6 cm x 1.5 cm 04/27/23: 8 cm (centimeters) x 6 cm x 1.5 cm On 5/02/23 at 11:00 AM, V13 (Wound Care Coordinator) was observed performing wound care on R7. The sacral pressure ulcer was observed open, with current measurement of 7 cm x 5 cm x 2.8 cm. Per V13, the sacral wound is 30-40% slough, 60-70% granulation. A tan colored slough is covering almost half of the wound bed. During cleansing, the sacral wound was bleeding in minimal amount. Subsequently, the wound was treated as ordered and covered with dressing. R7 was asked if she is repositioned when in bed. R7 stated, I'm not turned every two hours, staff don't do that. My back wound stays the same, been a while. On 05/03/23, R7 was observed for repositioning. The following were noted: 9:20 AM - lying on back 9:40 AM - lying on back 10:05 AM - lying on back 10:20 AM - lying on back. R7 stated she wants to get up because she wants her hair done on the first floor. Also stated that she has not been repositioned. 10:40 AM - lying on back 11:00 AM - CNAs (Certified Nurse Assistants) V6 and V21 were observed going into R7's room. V6 stated that she (R7) wants to be cleaned because she (R7) wanted to go to the first floor to get her (R7) hair done. R7 had to direct V6 to get her up. During provision of morning and incontinence care, as V6 turned her (R7) to her (R7) right side, the brief was observed wrinkled and soiled with minimal to moderate amount of blood coming from the wound. The sacral wound was exposed with no covered dressing. The incontinence pad was also wrinkled and soiled with blood. R7 was using a low air loss mattress covered with a flat sheet. On top of the flat sheet was the soiled incontinence pad. R7 was wearing an incontinence brief. V6 stated, she checked her (R7) around 9:45 AM and she was still dry. R7 verbalized, She checked me, yes but she just asked me how I was doing and if I needed anything. She did not check my brief. She (V6) did not turn me from side to side, never ever. At 11:15 AM, V13 came to clean her wound. V13 stated, We have PRN (when needed) treatment orders, unit nurse can change dressing when needed. CNAs need to tell nurses if the dressing is soiled or been removed during incontinence care. On 05/03/23 at 2:47 PM, V13 was interviewed regarding R7's pressure ulcer on the sacral area. V13 replied, CNAs should notify any new areas to unit nurse. Unit nurse should be doing skin assessment and alerting wound care. Treatment orders should be followed and implemented. Repositioning should be done at least every two hours at the very least. Incontinence care should also be implemented in improving wound status. For low air loss mattress, one flat sheet only. There should be no more than two layers, could be the pad or the brief. Multiple layers would inhibit the functioning of the mattress. R7 should not be wearing the brief. Wound should be covered all the time, to prevent infection. CNAs should be notifying nurses if dressing gets soiled or removed so it could be replaced. R7's care plan on actual impaired skin integrity related to skin breakdown related to decreased mobility and incontinence of bladder secondary to Cervical Spine Injury, current skin breakdown of increased severity, history of Osteomyelitis; potential for signs and symptoms of ongoing and recurrent complications of delayed healing, signs and symptoms of new breakdown, and infection, documented the following interventions: apply treatments as ordered; encourage/assist resident to change position as often as possible; keep skin clean and dry; avoid friction and shearing; specialty bed surface; incontinence briefs/pads, change PRN. V11 (Wound Nurse Practitioner) was asked on 05/03/23 at 1:51 PM about R7's sacral pressure ulcer. V11 stated, Been seeing her for a couple of months now. She has a sacral wound, Stage 4. The wound is stable, no complications from last time I saw her, that was last 04/27/23. She was admitted with Osteomyelitis in the sacral wound. She is incontinent, immobile, and getting a lot of moisture due to her incontinence. It is not okay for the wound not to be covered. She should have a dressing and should be dry all the time. If her wound has 30-40% slough on wound bed, the slough should not be expected on the wound. Presence of slough means there is dead tissue, necrotic tissue and it needs to come off by debridement or medications. V11 stated dead tissue competes with healthy tissue and needs to get out. Slough is not normal but if it's there, it is indicative that tissue is dying, and wound is not improving. Repositioning relieves pressure on the wound and helps in healing. Wound progress notes dated 05/04/23 recorded: Wound measurements sacrum - 8.0 cm x 7.0 cm x 1.5 cm. Manufacturer's guidelines for the use of the low air loss mattress stated in part but not limited to the following: Operating Instructions Step 5 Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient. Facility's policy titled Pressure Ulcer Prevention revision date 1-15-18, documented in part but not limited to the following: Purpose: To prevent and treat pressure sores/ pressure injury. Guidelines: 4. Keep bottom sheet dry and tightly stretched and free of wrinkles. 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for fall prevention by not having effective fall interventions, not completing fall evaluations for each fall occurrence to determine root causes of falls, and to ensure proper transfer procedures were implemented for a resident who is totally dependent on staff for transfers. This failure applied to three of three residents (R4, R5, and R9) reviewed for accidents and supervision which resulted in R4 sustaining a spine fracture, R5 sustaining a leg fracture, and R9 experiencing repeated falls. Findings include: R4 is a [AGE] year-old female with a diagnoses and history of Unspecified Injury of Face Subsequent Encounter (as of 03/02/23), Unspecified Injury of Head Subsequent Encounter (as of 03/02/23), Head Bruise Subsequent Encounter (as of 03/02/23), Dementia without Behavioral Disturbance, History of Falling (as of 03/02/23), Abnormalities of Gait and Mobility, Lack of Coordination, and Late onset Alzheimer's Disease who was admitted to the facility 03/02/23. R4's most current physician orders included an active order effective 3/2/2023 for 10mg Donepezil (Cognition Enhancing Medication) by mouth at bedtime for Alzheimer. R4's care plan initiated 03/02/23 documents she is at risk for falls related to unawareness of safety needs, decreased mobility, and recent history of falls with injury with interventions including assure the floor is free of glare, liquids and foreign objects; continue with physical therapy for strengthening, encourage appropriate use of assistive device as applicable, utilizes wheelchair, keep call light and desired personal items within reach, maintain an environment free of clutter, observe for changes in ability to ambulate and/or move about, psych evaluation, recommend that resident use proper footwear, staff will offer and assist patient to rest in bed when noted restless in wheelchair. R4's care plan initiated 03/08/23 documents she is disoriented to person/place/time. Her memory is impaired. She has problems with decision-making, insight, logic, calculation, reasoning, planning, organization, sequencing, social skills and/or judgement. This problem is related to: diagnosis of Dementia with interventions including provide clear explanations regarding expectations and procedures prior to providing care; break tasks down into small, manageable sub-tasks. R4's progress note dated 3/4/2023 at 1:49 PM documents family stressed sun downs and Dementia, reassurance given to family and resident remained sitting up in chair at bedside with no attempts to get up. R4's fall scale evaluations dated 03/02/23, 03/05/23 and 03/30/23 documents she is a high risk for falls with a score of 75 with risks including an impaired gait and a history of falling. R4's post fall observation dated 03/30/23 documents she experienced an unwitnessed fall in the hallway; just prior to fall she was sitting during an unknown activity and using her wheelchair at the time, she was unable to state what happened, no injuries were noted. R4's progress note dated 3/30/2023 12:20 AM documents writer received patient at the nursing station. Patient was very agitated and wouldn't stay in her wheelchair. Patient was hitting the staff, screaming and biting the staff. Family was called and the physician was made aware and asked that the patient be sent out to the hospital; at 6:13 PM documented resident noted sitting at the nurses station in wheelchair screaming, staff attended to all needs and resident was redirected several times. Writer was assisting EMS (Emergency Medical Services) and upon turning to check on resident she was noted on the floor near nursing station screaming and yelling. R4 was noted sitting on her buttocks with the wheelchair sitting behind her. Family requested patient be sent out to emergency room for the fall. R4's progress note dated 3/31/2023 at 08:56 AM documents she was transferred to the hospital due to unwitnessed fall, call placed to hospital. Spoke with nurse at hospital who stated that patient was transferred to another hospital due to cervical fracture. Call placed to other hospital, spoke with nurse who stated that R4 will be admitted for confusion, cervical fracture with cervical collar in place and degenerative changes. Per hospital nurse R4 currently in restraints due to multiple behaviors as she attempted multiple times to get up and is pulling at cervical collar. Facility's Final Incident Investigation Report dated 04/05/23 documents on 03/30/23 R4 was observed sitting up in her wheelchair by the nurses station and was redirected multiple times after attempting to get up from her wheelchair and self-transferring by wheelchair away from the nurses station. R4 was noted to be yelling at staff. Before staff was able to reach her, she stood up and was observed sitting on the floor across from the nursing station. R4 displayed impulsive behavior during the incident and had no safety insight or safety awareness related to diagnoses. R4 was sent to the hospital emergency room for evaluation and a CT scan revealed a cervical fracture. R4's Hospital Record dated 03/30/23 documents she presented at the emergency room after an unwitnessed fall at the facility and was receiving care from a sitter while exhibiting increased agitation. On 05/03/23 from 10:36 AM - 11:26 AM V15 (Licensed Practical Nurse) stated R4 was calmer in the morning but exhibited sundowning daily from 2PM - 11PM. V15 stated R4's sundowning behavior included screaming, not wanting to go to bed or be changed, wanting to walk when she can't, and not wanting to be talked to. V15 stated some days it's possible to get R4 to sit at the nurse's station by her and talk or keep her busy with things like sorting papers or writing stuff out or talking to her about [NAME] and what she liked to do or eat. V15 stated there's always two nurses and four CNA's (Certified Nursing Assistants) that typically work during the 3- 11/11:30 PM shift. V15 stated R4 never refused medication. V15 stated when she arrived to work at 3PM 03/30/23 R4 was already screaming. V15 stated when R4 is sundowning she thinks someone is trying to kill her, and says things like why am I here, and doesn't want anyone to touch her. V15 stated R4 fell around the middle of her shift. V15 stated during the time of R4's fall it was between 6-8 PM during the time medications are being passed and residents are being placed in bed. V15 stated she only remembers her and R4 being at the nurse's station during the time of her incident. V15 stated when R4 fell she had just received a new patient in the facility that had been brought in by EMS (Emergency Medical Services) personnel. V15 stated while she was looking down at documents and completing and signing paperwork for the new resident the EMS driver began communicating with her while he was getting on the elevator. V15 stated she turned her head towards the EMS to communicate with him and when she turned back toward R4 she was on the floor. V15 stated just before R4 fell she was calm and in a low tone asking for her daughter, grandson, and expressing she wanted to go home. V15 stated when the residents come from dinner, the ones who are fall risks are placed by the nurse's station and R4 was sitting by the nurse's station during her incident. V15 stated R4 had refused to be changed so the staff were giving her time before reattempting. V15 stated several times before R4 fell she had to be redirected because she was attempting to get up out of her wheelchair and was up and out of the chair a few times. V15 stated staff had to run over and catch R4 because she was getting out of her chair. V15 stated in order for R4 to comply with sitting down in her wheelchair you have to go over to her or be right next to her. V15 stated R4 was a few feet away on the other side of the nurse's station between the medication room and the water fountain when she fell. V15 stated R4 was not within her reach when she fell. V15 stated she was passing medications when the new resident arrived and had to go and get the paperwork for the new resident and was not directly next to R4 at the time of her fall. V15 stated if she was closer to R4 when she fell, she would have seen her attempting to get up and been able to redirect her. On 05/03/23 from 12:24 PM - 1:50 PM V1 (Administrator) stated residents are supervised from the nurse's station. V1 stated the adequacy of supervision for a resident would depend on the entire plan of care including supervision and depending on the resident's behavior. V1 and V4 (Assistant Director of Nursing) stated R4 may not have been adequately supervised based on her reported behaviors of repeatedly attempting to get out of her chair prior to her fall on 03/30/23 and the nurse reporting R4 will only comply with redirection to remain in her chair when someone is directly next to her. V1 and V4 agreed that it was unlikely that V15 (Licensed Practical Nurse) could reach R4 in time to break her fall based on her distance from the nurse and the barrier of the nurse's station between her and the nurse during the time of her fall on 03/30/23. V1 and V4 agreed that R4's distance from the V15 during the time of her fall could have contributed to her fall. V1 and V4 agreed that V15 turning her head away to attend other duties during the period of time of R4's fall after R4 had been exhibiting behaviors of repeatedly trying to get out of her chair could have contributed to her fall on 03/30/23. R5 is an [AGE] year-old male with a diagnoses history of Partial Paralysis following Stroke, Vascular Dementia without Behavioral Disturbance, History of Falling (as of 08/31/21), and Anxiety Disorder who was originally admitted to the facility 06/08/2021. R5's Quarterly Minimum Data Set, dated [DATE] documents he requires total dependence on two staff for transfers, extensive one person assistance for bed mobility and toileting. R5's most current care plan initiated 06/29/22 documents he has the potential for vision impairment related to blindness in the left eye; potential for impaired safety with interventions including implement and maintain safety precautions. Tell him (R5) where you are placing his items. R5's most current care plan initiated 06/08/21 also documents he is at risk for falls related to Gait/balance problems, Psychoactive drug use, cognitive deficits, history of falling, CVA Left sided weakness, poor safety awareness, impulsive, limited mobility, poor vision, Anxiety Disorder. R5 has had a fall with no injury on 12/8/21; and he sustained a fall with no injury on 7/24/22 with interventions including: ensure resident is positioned and aligned in the middle of bed; anticipate and meet R5's needs; be sure R5's call light is within reach and encourage him to use it for assistance as needed, R5 needs prompt response to all requests for assistance; Ensure resident is positioned correctly in wheelchair; Ensure that R5 is wearing appropriate footwear when ambulating or mobilizing in wheelchair; he will have a dycem applied to his chair to prevent slipping out of chair. Review information on past falls and attempt to determine cause of falls; record possible root causes; alter remove any potential causes if possible. Educate resident/family/caregivers/ and interdisciplinary team as to causes. R5's most current care plan initiated 07/22/22 documents he requires use of full body lift for transfer with diagnoses history including partial Paralysis and Dementia. R5's most current care plan initiated 01/06/23 documents he is at risk for falls due to Confusion, Incontinence, Poor communication/comprehension, Psychoactive drug use, unaware of safety needs; with diagnosis of partial paralysis following cerebral infarction, vascular dementia, and anxiety disorder with interventions including keep furniture in locked position; Keep needed items, water, etc. in reach; maintain a clear pathway, free of obstacles. Avoid repositioning furniture. R5's progress note dated 03/25/2023 9:15 PM documents CNA (Certified Nursing Assistant) reported to writer patient complaining of pain to right lower extremity. Patient voiced having pain to right leg while being transferred back to bed and during peri care. Assessment completed noted right lower extremity with very painful range of motion. Patient is unable to straighten his right leg and hip/femur is swollen and tender to touch. This writer noted patient sitting up in the chair when arrived this morning. Patient did not complain of pain during day shift and most of PM shift until placed back in bed. Patient screamed out in pain with movement of the right lower extremity. Page placed for the Nurse Practitioner. No incidence of a fall reported for this resident; 10:13 PM progress note documents spoke with Nurse Practitioner; order received to send the patient out to the emergency room. R5's 11:15 PM progress note documents patient with complaints of severe pain to the right hip and femur. Per CNA (Certified Nursing Assistant) patient normally can move right lower extremity and straighten leg on his own without assistance without pain; noted right hip area swelling with excess fluid with pain upon physical medical assessment. Recommendation was to send the resident out to emergency room for evaluation. R5's progress note dated 3/26/2023 09:49 AM documents resident returned from hospital with no new orders alert and awake. No abnormal musculoskeletal findings were observed in hospital assessment. Resident was administered as needed pain medication and transferred to chair to eat breakfast in dining room. R5's 7:38 PM progress note documents that upon further observation of hospital discharge records writer observed that resident refused x-ray of right hip at hospital. Resident continuously complains of pain of right hip. Writer recommends x- ray of right hip. Writer left message for on call service for update, no call back at this time. R5's progress note dated 3/27/2023 10:07 AM documents new orders given by Nurse Practitioner for immediate x-ray to right hip due to complaints of pain. R5's progress note dated 3/28/2023 10:28 AM documents: resident complained of pain when right leg moved, Nurse Practitioner present at facility and examined resident, new orders received for immediate x-rays. R5's 12:03 PM progress note documents x-ray results relayed to Nurse Practitioner of right thigh fracture. New orders to send to hospital. R5's Hospital Record Dated 03/28/23 documents he was admitted for an unwitnessed fall, nontraumatic fracture of right hip, came from nursing home and is not able to give history, was seen in the emergency room two days prior due to right hip pain, it appears that an x-ray was not done at the time of initial presentation to the hospital, an x-ray was performed during this visit to the hospital and revealed a right thigh fracture. R5's progress note dated 3/29/2023 09:49 AM documents he was admitted to the hospital with a diagnosis of Right Thigh Fracture. R5's March 2023 Medication Administration Record documents he was assessed to have a pain level of 7 during the evening shift on Saturday 03/25/23 and during the morning shift on Sunday 03/26/23, and a pain level of 0 from the evening shift on Sunday 03/26/23 - the morning shift on Tuesday 03/28/23. Facility's Final Incident Investigation Report dated 04/03/23 documents on 03/25/23 while providing bedtime care for R5 CNA (Certified Nursing Assistant) observed swelling to R5's right hip, the inability of R5 to straighten his right leg, and appeared to be in pain with movement. R5's Nurse Practitioner was notified, and an order was given to transfer him to the hospital emergency room. On 03/28/23 he was examined by the Nurse Practitioner and an immediate x-ray was performed and revealed an acute right thigh fracture. An order was given to send R5 to the hospital emergency room for further evaluation and treatment. R5 was determined not to have a fall based on interviews with staff and other providers. V16 (Family Member) visited on 03/24/23 and reported no fall incidents. R5 underwent right hip surgery on 03/28/23 at the hospital and remains hospitalized at the time of this report; V22 (Certified Nursing Assistant) was interviewed and stated on 03/25/23 later on during the shift R5 complained of right hip pain when being moved after being transferred to his bed while receiving bedtime care, he was observed with swelling in right hip area and was unable to straighten his leg, the nurse was informed of his condition. A Disciplinary Report dated 03/30/23 included in the investigation packet documents V22 failed to follow care instructions for a resident during transfer and received an immediate warning; a non-dated in-service included in the investigation packet documents V22 was in-serviced regarding following resident's transfer status and care plan; there were no resident interviews other than R5 included in the investigation reports nor any documentation that there were no residents who may have had any direct knowledge of the incident. On 05/03/23 from 12:24 PM - 1:50 PM V1 (Administrator) stated while investigating an injury of unknown origin staff would be interviewed regarding interactions leading up to an injury of unknown origin. V4 (Assistant Director of Nursing) stated you can also interview family, the patient themselves and other residents if they are cognitively able to provide information to determine if they have any information on the potential cause of the injury of unknown origin. V1 stated even if the facility is unable to determine the exact cause of an injury of unknown origin after investigating the cause of the injury, the resident's injury is still the facility's responsibility. On 05/04/23 from 10:27 AM - 10:43 AM V9 (Licensed Practical Nurse) stated R5 did not complain of pain on Friday 03/24/23 when she worked. V9 stated she was off Saturday and Sunday 03/25/23 and 03/26/23. V9 stated when she came back to work on Monday 03/27/23 R5 complained of pain in his legs and an x-ray was done at the facility, but it was inconclusive. V9 stated R5 was still complaining of pain on Tuesday 03/28/23 and the Nurse Practitioner saw him in person and ordered another x-ray. V9 stated another portable in-house x-ray was done on 03/28/23 and it revealed a fracture. V9 stated it seemed like R5's injury happened over the weekend because he did not complain of pain prior to this. V9 stated she believes R5 went to the hospital on [DATE]. V9 stated R5 only complained of pain when being moved. V9 stated whenever R5's fractured leg was touched then he would report pain. V9 stated R5's complaints of pain were not constant. V9 stated R5 may have a diagnosis of Chronic Pain but did not usually ask for pain medications which is why his complaints of pain leading up to the discovery of a fracture was unusual. V9 stated R5 requires transfer by mechanical lift. V9 stated R5 is usually up in either a reclining chair or high back wheelchair, but she can't be sure which type of chair. V9 stated R5 is normally gotten up daily and has breakfast and remains out of bed. V9 stated R5 is also changed throughout the shift and is placed back in bed in the evening. On 05/04/23 from 1:44 PM - 2:03 PM V4 (Assistant Director of Nursing) stated the nurse should have attempted again to reach out to the doctor to see if R5 would be receptive to being x-rayed after the nurse observed him to be in continuous pain and made an attempt to reach the physician on the evening shift 03/26/23. V4 stated she can't explain what R5's outcome might be from the lack of additional attempts by the nurse to reach the physician on 03/26/23. V4 stated she is not sure why R5's March Medication Administration Record documented pain levels of 0 from the evening of 03/26/23 - the evening of 03/28/23 although his progress notes from 03/26/23 indicated he was in continuous pain. V4 stated she cannot explain how R5 may have sustained his fracture if he didn't fall while in the facility. R9 is an [AGE] year-old male with a diagnoses history of Partial Paralysis following a Stroke, Repeated Falls (present on admission), Dementia without Behavioral Disturbance, Degenerative Disease of the Nervous System and Blindness who was admitted to the facility 07/08/22. On 05/02/23 at 2:19 PM R9 was observed lying in his bed listening to the television. Observed R9 was observed wearing regular socks and R9 had floor mats on both sided of R9's bed. From 05/01/23 - 05/03/23 during the course of the complaint survey while making rounds suveyor did not observe R9 out of his bed and or participating in activities. R9's current care plan initiated 08/29/22 documents he is at high risk for falls related to gait/balance problems, history of falls, and impaired vision with interventions including staff to monitor for altered mental status or acute infection, encourage to call for assistance before attempting to toilet self or transfer, offer and assist to lay down after meals, psych evaluation (initiated 02/28/23), Encourage activities that minimize the potential for falls while providing diversion and distraction, Encourage to participate in activities that promote exercise and physical activity for strengthening and improved mobility, and Physical Therapy to evaluate and treat as ordered or as needed. R9's current care plan initiated 10/03/22 documents he demonstrates behavioral distress as manifested by Verbally abusive behavior; Use of profanity, demeaning statements, verbal threats, and yelling; Racial/ethnic/religious/gender slurs. With interventions including Ask the resident to calmly explain what is causing this upsetting behavior. Praise the resident for speaking calmly and appropriately, If the resident becomes verbally or physically abusive, attempt to calm the resident, by explaining that ladies and gentlemen do not talk or behave this way. R9's current care plan initiated 08/05/22 documents he exhibits the symptoms of rejecting care, places self on ground as a behavior if immediate attention is not given, with interventions including evaluate when the best time of day is to provide care. Provide care consistent with the person's schedule, as possible, give psychoactive medication, as ordered, refer the resident to the consulting psychiatrist for a psychiatric evaluation, as warranted, staff will encourage safe coping skills to help avoid possible falls due to behaviors. R9's current care plan initiated 10/22/22 documents the resident presents with signs and symptoms of Delirium such as recent onset or worsening of symptoms, including becoming easily distracted; paranoia, periods of altered perception/awareness inattention; episodes of disorganized speech; periods of restlessness; periods of lethargy; mental function varying over course of the day. Signs and symptoms are related to: Dementia with interventions including Review medical and psychosocial evaluations to assess potential delirium causes and contributing factors. Delirium is typically caused by several factors. Rule out serious illness/worsening of an acute illness; Review medication interactions. Look for drug toxicity, Review medication and food interaction, Check food and fluid intake. Review weight records. R9's Fall Evaluations from admission to Current document he is a high risk for falls. R9's progress note dated 08/26/22 documents R9 was observed yelling out repeatedly help me help me I'm on the floor, exhibited signs of confusion and behaviors and it was endorsed to shift to request a psych consult. R9's Post Fall Observation dated 08/26/22 11:30 AM documents he experienced an unwitnessed fall while lying in his bed engaging in leisurely activity in his room. Resident was reaching for call light. R9's progress note dated 10/7/2022 2:05 PM documents patient observed on the floor in his room in a side lying position on the side of the bed. Resident stated that he was attempting to go to the bathroom. Resident with complaints of pain to the right knee. R9's Post Fall Observation dated 10/7/2022 12:40 PM documents he experienced an unwitnessed fall while sitting in his room. Resident stated he was trying to go to the washroom. He experienced pain in his right knee and was provided pain medication. R9's progress note dated 12/22/2022 11:58 AM documents R9 has had a recent fall. Please refer to the Post Fall Observation for details. R9's Post Fall Observation dated 12/22/22 11:58 AM documents he experienced a witnessed fall while sitting in the lounge or dayroom engaging in leisurely activity. R9 stated he was trying to get in his wheelchair to go to bed. R9's progress note dated 12/22/2022 5:03 PM documents at 4:43PM writer notified by day nurse that resident is sitting next to bed on the floor upright, writer walked into room with male certified nursing assistant and noted resident attempting to get up. R9 stated he was reaching for his phone and just sat on floor because felt he was going to fall. R9's Post Fall Observation dated 12/22/22 4:43 PM documents he experienced an unwitnessed fall while in his room lying in bed. R9 stated he was reaching for his phone and just sat on floor because felt he was going to fall. R9 was wearing skid grip socks at the time. R9's progress note dated 12/28/2022 12:57 AM documents writer notified by certified nursing assistant that resident is sitting next to his chair in the day room. Writer walked into room with staff nurses on the floor and noted resident attempting to get up. R9 stated he tried to slide to the floor. R9 started shouting profanity at the staff. Requesting psych evaluation. R9's Post Fall Observation dated 12/28/2022 1:06 PM documents he experienced an unwitnessed fall while sitting in the dayroom or lounge. The resident stated he slid himself onto the floor from his wheelchair. R9's Nurse Practitioner progress note dated 1/2/2023 9:59 PM documents Chief Complaint of Multiple falls. Patient asked to be seen due to multiple falls. Patient sustained a fall twice in a week, noted to be due to behavior issues. R9's progress note dated 1/4/2023 10:02 PM documents Chief Complaint of Multiple falls, now with increased behavior issues. Patient was seen resting on his bed, agitated and anxious at the visit. Patient trying to get up from his bed walk independently, was redirected back to the bed. Patient had sustained to fall recently, will check labs. Assessment and Plan includes increased behavior issue. Other etiology could be worsening dementia as well. Accusing staff of stealing his belongings. Patient with attention seeking behavior. R9's progress note dated 1/21/2023 3:32 AM documents R9 has had a recent fall. Please refer to the Post Fall Observation for details. R9's Post Fall Observation dated 1/21/2023 03:32 AM documents he experienced an unwitnessed fall while in his room lying in his bed sleeping, he was wearing regular socks at the time. R9 reported I don't know what happened and I was trying to get up. R9's progress note dated 2/15/2023 8:12 PM documents Resident is threatening to drop himself on the floor if service request isnt done on time. R9 called a certified nursing assistant for help to get changed but a certified nursing assistant was busy with another patient. R9 pushed himself to the floor to get a quicker response. R9's progress note dated 2/18/2023 6:33 PM documents approximately 6:20 PM during med pass. Writer was reported to by certified nursing assistant that she observed patient lying supine on the floor in the hallway. Writer went to assess R9, and he was still lying supine. R9 was unable to verbalize how he had fallen. R9 unable to verbalize where he was experiencing pain. Nurse Practitioner was notified, verbal order to send R9 to the hospital emergency room. R9's Hospital Record dated 02/18/23 documents he presented to the hospital emergency room from the facility after an unwitnessed fall. R9 was found in the hallway on the ground. Per the emergency medical services personnel R9 stated at the time he was hurting all over. The hospital Registered Nurse spoke with the facility Registered Nurse, and it was reported that he was in significant pain after the fall. R9's progress note dated 2/24/2023 10:04 AM documents Alerted to residents' room, observed resident laying on floor alert verbal complaints of right sided rib pain, resident also stated he bumped his head, R9 is going to be transferring to the hospital emergency room. R9's progress note dated 2/28/2023 07:05 AM documents writer found the resident on the floor upon shift rounds. Resident has confused mental state. Contacted the physician, suggests the resident is sent out for psych evaluation. R9 was transported to the hospital. R9's progress note dated 3/27/2023 5:27 PM documents resident was angry and tried to get out of the bed without any assistance from staff. Resident was observed with his feet on his floor mats sliding himself onto the floor mat. Resident stated he wanted to walk by himself. Resident was re-oriented to ring his call light for assistance out of his bed. R9's progress note dated 3/29/2023 7:18 PM documents Resident was angry and tried to get out of bed without staff assistance. Resident was observed sitting on his floor mat. R9's progress note dated 4/2/2023 2:29 PM documents Writer called to sitting area that resident observed sitting on floor upright. R9's Post Fall Observation dated 4/2/2023 2:31 PM documents he experienced an unwitnessed fall while sitting in the dayroom or lounge during a leisurely activity. He was wearing regular socks at the time. R9's progress note dated 4/18/2023 6:26 PM documents R9 has had a recent fall. Please refer to the Post Fall Observation for details; at 6:52 PM Resident slid himself onto the floor in a rage. The resident was transported from the floor to the wheelchair. R9's Post Fall Observation dated 4/18/2023 6:26 PM documents he experienced a witnessed fall while sitting in the dayroom or lounge during a leisurely activity. Resident stated he was upset he didn't receive a snack immediately and slid himself on to the floor. There were no post fall evaluations completed for R9's falls on 02/15/23, 02/18/23, 02/24/23, 02/28/23, 03/27/23, and 03/29/23. R9's Behavior Diagnostic assessment dated [DATE] documents he is stressed about his money and whether his daughter is taking good care of it, he reports symptoms of frequent depression and less frequently anxiety; staff reports he can be impulsive and this has led to his falling on a few occasions; he is open and receptive to talking with therapist; patient has some dementia but will likely benefit from therapy to cope with losses and his anxiety. R9's Psychological Services Progress note dated 04/20/23 documents he reported being unable to sleep well at night, he sometimes gets very drowsy and has to go lay down. His plan includes visiting with him again in two weeks and provide support as he is coping with the loss of independence particularly his daughter managing his money and his need to get assistance with his ADL's (Activities of Daily Living), will provide an outlet for patient to talk about his concerns. Sessions scheduled every two weeks. R9 expressed appreciation for the opportunity to talk with therapist. On 05/04/23 at 10:22 AM R9 stated he does feel sad and depressed, and it does make him sad that he can't move around the way he used to. R9 stated if he could get a long a little better it would make him feel better. R9 stated he wants to be gotten out of bed and wants to be moved around. R9 stated he would like to be moved around a little more. R9 stated the facility doesn't get him out of bed very often. On 05/03/23 from 12:24 PM - 1:50 PM V1 (Administrator) stated residents are sup[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow professional standards of quality care and adequately monitor oxygen saturation levels for one resident (R10) out of three reviewed for change in respiratory status. This failure resulted in R10 being sent to the local hospital for hypoxic respiratory failure. Findings include: On [DATE] at 9:38am, V21 (nurse) stated that V21 does recall R10. V21 stated that V21 does recall that R10 would remove nasal cannula at times. V21 stated that when V21 assessed R10, the nasal cannula prongs were not completely in R10's nose. V21 stated that V21 repositioned the nasal cannula prongs further into R10's nose. V21 stated that V21 does not recall any further details on the event on [DATE]. V21 stated that V21 charted all the details in R10's medical record. On [DATE] at 1:40pm, V37 NP (nurse practitioner) stated that she is unsure reason staff were not monitoring R10's respiratory status and oxygen saturation levels, but staff should be following these facilities policies. V37 stated that V37 would expect staff to be monitoring vital signs, including respirations and oxygen saturation level at least every shift. V37 stated that for residents receiving supplemental oxygenation, the nurse needs to be checking their oxygenation level. V37 stated that if a resident's oxygen saturation level drops to 82-84% on oxygen, the nurse should increase the resident's oxygen, remain with the resident to monitor status, and call EMS 911. V37 stated that with nasal cannula, can administer up to 8 liters of oxygen. If more than 8 liters is needed to get oxygen saturation level up into the 90s, the nurse should change to a non-rebreather mask. V37 stated that V37 would have expected the nurse to increase oxygen up to 8 liters and monitor R10's oxygen saturation level to see if it was improving and continue monitoring until EMS paramedics arrived and took over R10's care. Review of R10's medical record, dated [DATE] at 6:00am, V21 (nurse) noted: V21 was called to R10's room by CNA (certified nurse aide) staff, who reported R10 unresponsive. V21 assessed R10 and noted R10 to be very lethargic during assessment and non-responsive to tactile stimuli. R10 had shallow breathing and oxygen saturation level between 82-84% at 3 liters oxygen via nasal cannula. Vital signs: blood pressure 110/50, pulse 80 beats/minute, temperature 97.2 degrees, respirations 14/minute. EMS (emergency medical services) 911 call initiated and paramedics in route. On 1/18 at 6:16am, V21 noted paramedics x 3 arrived via ambulance and stretcher. R10 remains lethargic at this time with shallow respirations. R10 being transferred to the hospital per paramedics. On [DATE] the nurse noted R10 was admitted with a diagnosis of cardiac arrest. There is no documentation found in R10's medical record noting any interventions (increasing amount of oxygen, continuous oxygen saturation monitoring, monitoring respiratory status) were implemented on [DATE] prior to EMS 911 arrival. Review of R10's hospital medical record, dated [DATE], notes R10 presented to the emergency room at 6:40am. EMS 911 were called for a resident unresponsiveness. Last known normal is unknown. Upon EMS arrival at R10's bedside, R10 had agonal respirations (gasping for air during a serious medical emergency). R10 initially had a heartbeat but then lost it shortly after EMS' arrival. CPR (cardiopulmonary resuscitation) was initiated, and medication administered; return of spontaneous circulation was obtained. R10 remained with no movements and no improvement in mental status. R10's pupils minimally reactive. Distant breath sounds throughout lungs. R10 with generalized edema (swelling) throughout. R10 was intubated and placed on a ventilator. By 9:28am, R10's bilateral pupils were nonreactive and remains unresponsive. R10 expired on [DATE] at 6:40pm, cause of death: hypoxic respiratory failure. Review of R10's EMS run sheet, dated [DATE], notes the facility contacted EMS at 5:53am. EMS crew was dispatched and arrived at the facility at 5:58am. EMS crew at R10's bedside at 6:00am and found R10 unresponsive in bed. R10's respirations were 6-8 breaths/minute and shallow. R10 was quickly transferred to cot and ventilations were assisted to R10. As soon as R10 was placed in ambulance, R10 went pulseless and without any respirations. CPR was performed and ventilations continued. Return of spontaneous circulation was obtained. R10 remained unresponsive. Review of R10's medical record notes R10 was admitted to this facility on [DATE] with diagnosis including hypertensive heart disease and shortness of breath. Review of R10's medical record notes R10's respirations and oxygen saturation level were last documented on [DATE]. Review of R10's medical record notes V49's (attending physician) last documented face to face visit with R10 was on [DATE]. V37's NP (nurse practitioner) last documented face to face visit with R10 was on [DATE]. Review of R10's chest x-ray, dated [DATE], notes x-ray results were reported on 1/5 at 11:48pm. Results show infiltrates in both lung bases. This report was reviewed by V50 RN (registered nurse) on [DATE] at 1:15pm. Review of R10's POS (physician order sheet), dated [DATE], oxygen at 2 liters per nasal cannula continuous. On [DATE], notes an order for vital signs every shift x 14 days then daily. On [DATE], notes an order for chest x-ray diagnosis shortness of breath. On [DATE], orders for doxycycline (antibiotic) and Augmentin (antibiotic) oral twice daily times 10 days for pneumonia. There is no documentation in R10's medical record noting reason antibiotics were not started until [DATE] when chest x-ray results were reported on [DATE]. Review of R10's admission physician note, dated [DATE], notes R10 presented to the outside hospital after an unwitnessed fall in the bathroom where R10 landed on both knees. During hospital stay, R10 underwent surgery to both femurs. R10's hospital course was complicated by hypoxia requiring BIPAP and CPAP (both are non-invasive ventilation therapies to treat respiratory distress). R10 was medically stabilized however not yet at her functional baseline and was admitted to this facility on [DATE] for course of subacute rehabilitation. Per V1 (administrator) this facility does not have an oxygen saturation level monitoring policy or an oxygen administration policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, this facility failed to follow their pressure sore prevention protocols for a resident assessed to be at moderate risk for skin breakdown. This affected 1 of 3 residents reviewed for pressure sore prevention. This failure resulted in R2 developing an unstageable pressure wound 10 days after admission. Finding Include: R2 was admitted in the facility with no skin issue, documented on 12/2/22 as skin intact. R2's Braden scale (Identifies patients at risk for pressure ulcers) score is 13 (Moderate Risk for skin alteration). R2 developed a pressure injury on R2's sacral area documented first on 12/12/22. The facility wound care team seen R2 on 12/13/22, seen by facility wound care nurse. Wound care team noted on 12/13/22 facility-acquired pressure ulceration epithelial or red=20%, slough white fibrous=80%, 5cm (L) x 5 cm (W) x unknown (D). R2 was seen by the Wound Nurse Practitioner on 12/15/22. Initial evaluation reveals unstageable pressure injury on sacrum. There is minimal to moderate amount of serous exudate. Significant contributors include generalized muscle weakness, impaired mobility, and inevitable effects of aging. Initial wound encounter measurements are 5cm x 5cm x 0.1 (L x W x D) treatment was medi-honey and cover with dry dressing change daily and as needed. V2 (DON) documented on 12/12/22, reads in part: Family thanked writer at end of conversation. NP notified of resident's new skin condition, new order received for Tylenol 1000mg q/every 6 hours as needed for pain, low air loss mattress, and ensure to be added to diet due to poor appetite. New orders noted and carried out. Surveyor interview of V2 on 3/22/23, V2 stated that she informed the wound care team at the facility. V2 did not see the wound of R2 and the only orders that was put in place were the three mentioned in her documentation on 12/12/22. V2 does not recall entering any wound treatment order but remembers informing the wound care team of the new skin condition. On 3/14/23 at 1:15pm, V3 (Wound Treatment Nurse) stated R2 skin intact upon admission [DATE] and on 12/12/22 identified by the nurse. On 12/13/22 was seen by me (wound nurse). One site, sacrum, unstageable. Measurement 5cm x 5cm, and the depth was unknown. There is a necrotic tissue covering the wound and the depth cannot be determine. Facility provided R2's TAR (Treatment Administration Record) for December 2022 reviewed. Order with a start date of 12/15/22 and discontinued date of 12/16/22, Sacrum: medihoney every day shift every Tuesday, Thursday and Saturday, cleanse with NSS (Normal Saline Solution), pat dry, apply medi honey to sacrum, zinc oxide barrier cream to periwound, cover with dry dressing and this is the first documented treatment for R2's sacral wound, then on 12/17/22, the second documented treatment for R2. No treatment on 12/12/22 when it was initially observed, none on 12/13/22 when the wound care team seen the wound, and none on 12/16/22. There was an order for as needed wound treatment order for sacral, but no signature noted in TAR that as needed order was rendered at all. Facility Policy for Pressure Injury and Skin Assessment with a revision date of 1/17/18, reads in part: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to charge nurse who will perform the detailed assessment. Physician ordered treatment shall be initiated by the staff on the electronic Treatment Administration Record (TAR) after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses noted.

R11 was admitted to the facility in 5/27/21 with a diagnosis of alzheimer's disease, dysphagia, dementia hypertension, history of falling, and venous insufficiency. R11's brief interview for mental status dated 2/22/23 documents a score of 3/15 which indicates severe cognitive impairment. Section G under eating documents: 3-Extensive assistance- resident involved in the activity, staff provide weight bearing support and one-person physical assist. R11's dietary slip documents: Aspiration precautions and feeding assistance. On 3/22/23 at 1:13PM, V28 (MDS) stated for minimum data set for eating with a score of 3- extensive assistance and a score of 2- one-person physical assist indicates that resident is being feed by staff. On 3/23/23 at 12:55pm, V20 (speech) stated R11 needs one to one feeding due to dementia, she may not know how to use a spoon or pick up a cup. On 3/22/23 at 3:25pm, V31 (Nurse) stated she observed R11 near the elevator. V31 stated she was on the other side of the nursing station at her medication cart. V31 stated she saw R11 leaning forward and fell out of her chair. R11 was eating ice cream prior to the fall and the ice cream was on the floor and it appeared that R11 was trying to reach the ice cream cup on the floor causing her to fall. R11 complained of pain to her right wrist. On 3/22/23 at 2:16pm, V33 (restorative nurse) stated staff should be monitoring R11 while she is eating in case, she needs assistance or monitoring because she has dysphasia and is at risk for choking. V33 stated the fall on 3/6/23 occurred when R11 was sitting in her wheelchair and fell forward trying to pick up something possibly the ice cream off the floor. V33 stated R11 has no history of falls. R11's facility incident report dated 3/6/23 under description: Resident stated she wasn't sure how she fell. Witness statements: V31(Nurse) dated 3/6/23 documents: writer witnessed the resident fall from her wheelchair onto the floor. Prior to the fall R11 was sitting in her wheelchair eating ice cream. R11 lost her balance and fell forward out of her wheelchair, The resident landed on her right side and stated she had pain to her right wrist, R11 facility final reportable dated 3/9/23 documents: On 3/6/23 at approximately 3:50PM, resident observed by staff sitting in her wheelchair near the nurse's station, eating ice cream from a cup. At approximately 3:55PM, staff observed resident lean forward as if she was attempting to pick something up off the floor. R11 was then observed falling out of her wheelchair on her right side. Ice cream cup noted near resident's foot. R11's radiology results dated 3/6/23 documents: under right hand x-ray impression acute hairline distal radial intra-articular fracture. R11's care plan revised on 6/2/22 documents: R11 has difficulty swallowing and has the potential for choking, aspiration and other adverse events. Interventions revised 11/4/21 documents: Speech therapy recommends diet texture to mechanical soft/thin liquids given close supervision for cues to use general aspiration/reflux precautions. R11's care plan revised on 2/2/23 documents R11 had a functional deficient in her self-performance for eating related to cognitive impairment due to dementia. She requires supervision with verbal cues. Intervention cue/assist R11 to spear food with fork/scoop food with spoon. Based on interviews and records reviewed, the facility failed to ensure safety while providing direct resident care. The facility also failed to monitor one resident with history of dysphagia and required one person feeding assistance who was eating ice cream in the hallway to prevent an avoidable fall incident. This affected 2 of 3 (R10, R11) reviewed for safety and avoidable accidents. This failure resulted in R10 rolling out of bed during care and sustaining a left oblique distal femur fracture and a right mildly comminuted oblique distal femur fracture with minimal displacement. R11 fell out of her wheelchair attempting to pick up ice cream cup, sustaining a wrist fracture. Findings include: On 3/22/23 at 11:00am, V2 DON (director of nursing) stated that R10 informed V2 that R10 had a fall while receiving ADL care. V2 stated that V2 had just started working at this facility in September 2022 and was just getting adjusted to facility at the time of R10's fall incident on 10/30/22. When asked to review staff interviews for further details of the incident, V2 stated that V2 did not keep any documented interviews she may have conducted related to R10's fall event while receiving ADL care. V2 acknowledged that any staff interviews V2 may have done should be kept with the fall event. V2 stated that R10 was confused. V2 stated that this facility does not have a post falls policy. V2 stated that there is only a fall prevention policy. On 3/22/23 at 2:25pm, V33 (restorative nurse) stated that V2 DON is responsible for conducting staff interviews to obtain details of each resident fall. V33 stated that the fall protocol is to put immediate interventions in place for the resident then discuss the fall event in IDT (interdisciplinary team) meeting and determine what changes need to put in place to prevent further falls. V33 stated that V33 does not recall R10 or R10's fall on 10/30/22. V33 stated that the nurse should document a fall risk assessment after each fall. V33 stated that if the resident fall occurs when V33 is not present in facility, the nurse is expected to put interventions in place immediately as well as document the event and interventions implemented in the resident's medical record. V33 stated that R10's recent fall with fractures prior to admission to this facility is documented in the fall risk assessment as a history of falls. Review of R10's BIMS (brief interview of mental status) score, dated 10/28/22, notes R10's score was 14 out of 15. Review of R10's MDS (minimum data set), dated 10/28/22 and 1/18/23, notes R10 requires extensive assistance of two staff members with bed mobility. Review of V35's (physician) note, dated 11/1/22, notes R10 had a fall on 10/30/22 per chart, primary physician has ordered x-rays of lumbar spine, right arm, bilateral hips/pelvis, x-rays being taken at the bedside this morning. Pain regimen includes acetaminophen 1000mg (milligrams) twice daily and tramadol (pain medication) as needed. R10 reports pain in bilateral knees, mostly where incisions are located on the anterior and lateral aspects. R10 reports pain is constant and moderate, non-radiating, aching quality and improves somewhat with Acetaminophen/tylenol. On 11/2/22 at 3:12pm, V36 LPN (licensed practical nurse) noted: R10 verbalized that R10 had a fall on 10/30/22 while receiving care with her ADL'S. R10 is now complaining of pain to the right side of her body. Physician was called and left a message in regard to having an x-ray or her right arm and hip. On 11/2/22 at 3:23pm, V36 LPN noted V37 NP (nurse practitioner) gave orders to have an x-ray of bilateral hips and pelvis as well as the right arm. On 11/3/22, V5 ADON (assistant director of nursing) noted order received to include lumbar spine x ray due to R10's complaint of back pain per V37 NP at this time. Order placed, awaiting outside diagnostic imaging company arrival. 11/3/22, V37 NP, R10 seen today due to recent fall, per R10 she rolled out of bed, denies hitting her head, no bruising/hematoma noted on the head, R10 oriented x 3. Slight bruising noted to left neck most likely secondary to nasal cannula pulling when R10 fell. Staff to monitor for changes in mentation, activity intolerance, complains of pain. Maintain facilities fall prevention strategies, follow facilities post fall policy including neurological checks. Monitor neck bruising. There are, no post fall head to toe body assessment or post fall risk assessment documented in R10's medical record after fall on 10/30/22. Review of R10's medical record notes R10 was admitted to this facility on 10/21/22 with diagnoses including right femur fracture, left femur fracture, and history of falling. Review of R10's admission fall risk assessment, dated 10/21/22, notes regarding the history of falling, it is documented 'no'. Review of R10's fall risk assessment, dated 11/23/22, notes regarding the history of falling, it is documented 'no'. Review of R10's fall incident report, dated 11/2/22 at 3:03pm, notes R10 verbalized that R10 had a fall on Sunday, 10/30/22, while receiving care with her ADLs. There is no post fall assessment by the interdisciplinary team to determine root cause of fall to prevent further falls from occurring. Review of R10's admission note, dated 10/22/22, the physician noted R10 presented to the outside hospital after an unwitnessed fall in the bathroom where R10 landed on both knees. Bilateral knee x-rays revealed a left oblique distal femur fracture and a right mildly comminuted oblique distal femur fracture with minimal displacement. Orthopedic surgery consulted, R10 underwent surgery to both femurs. R10 was medically stabilized however not yet at her functional baseline and was admitted to this facility on 10/22/2022 for course of subacute rehabilitation.

Based on interviews and records reviewed, the facility failed to accurately assess residents impaired nutritional status, implement, monitor, and evaluate the effectiveness of interventions for two residents (R3 and R4) reviewed for nutrition and hydration in a sample of 7. These failures resulted in R4 experiencing a mental change in condition and taken the local hospital. R4 was diagnosed and treated for dehydration, critically high potassium level, and acute kidney failure. R3 experienced an unplanned weight loss over a 30-day period without any interventions. Findings include: On 3/17/23 at 11:00am, V2 DON stated that V11 RD (registered dietitian) looks at all residents. V2 stated that the interdisciplinary team meets with V11 weekly to discuss residents. V2 stated that V2 is unsure if R4 was discussed at any of these meetings. V2 stated that recommendations made by V11 are discussed with V2, V8 ADON (assistant director of nursing), dietary manager, and restorative nurse and put in place. V2 stated that all residents are weighed monthly unless V11 recommends weekly monitoring. V2 stated that the staff are expected to document the percentage of each meal a resident consumes. V2 stated that the CNAs are expected to notify the nurse when a resident has poor intake or refuses meal. V2 stated that the nurse is expected to notify the physician and the resident's family when a resident does not eat a meal. When questioned how information is conveyed to nurses/CNAs when there is a recommendation to monitor oral intake. V2 stated that there is no order entered in the resident's medical record; CNAs are expected to document each meal. On 3/14/23 at 2:50pm, V4 (restorative aide) stated that R4 refused breakfast and lunch on 3/11/23 and refused breakfast on 3/12/23. V4 stated that R4 also refused to eat on 3/9/23. V4 stated that R4 did not receive a lunch meal because R4 was transported to the hospital. V4 stated that V4 usually can get R4 to eat sweets and drink coffee, but R4 refused. V4 stated that the rule is to let the nurse know if a resident is not eating. On 3/17/23 at 12:15pm, V4 stated that she took R4's weight on 3/12/23 but did not enter the result in R4's medical record. V4 stated that V4 did not enter R4's weight because R4 went out to the hospital the same day. V4 stated that she is not supposed to enter a weight if the resident goes to the hospital because the resident will be re-weighed upon re-admission. V4 stated that if a resident has a 5-pound weight change, the resident is re-weighed the following day or two. V4 stated that V4 always weighs R4 on wheelchair scale. V4 stated that on 3/12/23 R4's weight was 99.4 pounds. V4 stated that R4's weight was 102.7 pounds on 2/4/23. V4 stated that V4 knew R4 was not eating or drinking and knew R4's weight was off. On 3/16/23 at 12:35pm, V10 CNA (certified nurse aide) stated that V10 was assigned to provide care for R4 on 3/10/23 from 7:00am-3:00pm. V10 stated that R4 did not have an appetite on 3/10/23. V10 stated that R4 usually eats at least 25% of meal offered. V10 stated that R4 loves coffee. V10 stated that on 3/10/23, R4 informed V10 that she was tired and did not want to eat. V10 stated that V10 was able to get R4 to eat a couple of bites, R4 refused coffee. On 3/16/23 at 12:47pm, V12 CNA stated that on 3/10/23 R4 ate less than 50% of her dinner. When asked to clarify the discrepancy between what V12 charted and what V12 is stating about the amount R4 ate on 3/10/23, V12 stated that R4 ate less than 50% of dinner. V12 stated that R4 usually goes to the dining room to eat but on that day R4 did not want to get out of bed. V12 stated that R4 was very tired. V12 documented on 3/10/23 R4 ate 75% of dinner meal. On 3/17/23 at 11:53am, V11 RD (registered dietitian) stated that once monthly weights are done, V11 runs a monthly report and a weight changes report. V11 stated that V11 runs a weekly weight change report. V11 stated that V11 cannot remember if R4 was discussed during weekly interdisciplinary meetings. V11 stated that when she goes to the nursing units, she will ask the nurse if there are any changes. V11 stated that unless staff report any changes to V11, V11 will not know if a resident is not eating. V11 stated that only if a weight change is triggered in the report, V11 will review the amount eaten, interview staff for any changes, and complete an assessment and evaluation. V11 stated that R4's weight for March was not documented in R4's medical record. V11 stated that V11 was unable to review R4's weight and R4's weight loss would not be triggered on weekly weight change report. Review of R4's hospital medical record, dated 3/12/23, notes on previous emergency room visits, R4 had been able to state her name intermittently, answer questions, and answer some basic commands which appears to be changed in today's presentation. R4's initial vital signs taken at 12:47pm: heart rate 109 beats/minute, respirations 18/minute, and blood pressure 174/87. Physical examination noted R4 awake, not oriented, moaning, and not following commands. R4's mucous membranes dry. R4 with increased skin turgor. Potassium critically high at 6.3 (normal range 3.4-5.1), BUN (blood urea nitrogen) level 121 (normal range 6-20), creatinine 11.41 (normal range 0.51-0.95), GFR (glomerular filtration rate 3 (normal is greater than or equal to 60). Diagnoses: acute kidney failure-prerenal azotemia, elevated potassium level, dehydration, altered mental status. Admitting physician's assessment on 3/12/23 notes: R4 is ill-appearing, obtunded (diminished responsiveness to stimuli), cachectic (physical wasting with loss of weight and muscle mass), diffuse muscle wasting of all extremities, including temples, and dry mucous membranes. R4's baseline creatinine level around 1.3. Review of V11's RD (registered dietitian) note, dated 1/30/23, notes R4's estimated needs is 1543-1764 kilocalories, 44-53 grams of protein. R4's appetite is variable per meal records. R4 remains at high nutrition risk. Continue to monitor weight trends, laboratory test results, skin, and oral intake. Review of R4's dietary profile, dated 3/2/23, notes R4's BMI (body mass index) is 19 (R4 is underweight). R4's appetite is fair. R4 has chewing difficulties. Additional risk factors include BMI 20.9 or less. It also notes to monitor weights, skin, laboratory test results, and oral intake. Review of R4's weights notes: 3/12/23, weight was 99.4 pounds. 3.2% weight loss in one month. On 2/4/23, weight was 102.7 pounds On 1/1/23, weight was 103.9 pounds On 12/7/22, weight was 103.2 pounds On 11/2/22, weight was 104.9 pounds Review of R4's care plan, revised 12/19/22, notes R4 is at risk for continued weight loss related to poor appetite. Interventions include notify dietitian if oral consumption is poor more than 48 hours, administer medications as ordered, and provide nutritional supplements as ordered. Review of the amount R4 consumed at each meal for the past three months notes: January 2023, out of 93 opportunities for meals, staff documented 53 meals consumed. On 1/25/23, documentation notes R4 refused meal. February 2023, out of 84 opportunities for meals, staff documented 43 meals consumed. March 2023, out of 36 opportunities for meals, staff documented 11 meals consumed. On 3/11/23, documentation notes R4 refused breakfast and lunch. Review of the National Library of Medicine article dated 8/10/2022, notes azotemia is a biochemical abnormality, defined as elevation, or buildup of, nitrogenous products BUN, creatinine in the blood, and other secondary waste products within the body. Raising the level of nitrogenous waste is attributed to the inability of the renal system to filter (decreased glomerular filtration rate-GFR) such as waste products adequately. It is a typical feature of acute kidney injury. Prerenal azotemia is a subtype of azotemia. Acute kidney injury is generally diagnosed by an increase in creatinine by 0.3 mg/dL, creatinine increase greater than 1.5%. This diagnosis is made with urinalysis, urine electrolytes, metabolic panel and a renal ultrasound. Prerenal azotemia manifests from some insult/injury source before the kidney. Most commonly, we see this in the form of hypoperfusion, or decreased blood flow, to the kidneys from various etiologies of volume depletion, such as dehydration. Review of R3's POS (physician order sheet) notes an order, dated 2/22/23, enteral feedings at 65ml (milliliters)/hour x 12 hours, start at 8:00pm and stop at 8:00am. On 2/1/23, notes orders for dialysis every Monday, Wednesday, and Friday. There is an order for pre- and post- dialysis weights per dialysis center. There also is an order for a liberalized renal diet puree, nectar thick liquids. Review of R3's weight documentation notes: On 3/10/23, R3 weighed 179.8 pounds post dialysis. R3 had a 7.2% weight loss in one month. On 2/10/23, R3 weighed 193.8 pounds post dialysis. On 2/01/23, R3 weighed 190.5 pounds. On 1/10/23, R3 weighed 190.5 pounds. On 1/09/23, R3 weighed 188.7 pounds. There is no documentation found in R3's medical record noting weights were obtained per physician orders. There is no documentation found noting R3 was re-weighed to verify weights. Review of R3's meal consumption, dated 2/13/23-3/12/23, notes there were 84 opportunities for meals. There is documentation of 26 meals consumed by R3. Of these 26 meals, R3 refused meals on three occasions and was not available for two meals. Review of R3's nutrition care plan notes R3 is at risk for malnutrition and dehydration, weights per facility protocol. Review of V11's RD (registered dietitian) note, dated 2/18/23, notes enteral tube feeding provides 65% of estimated nutrition needs. Recent hospitalization 1/23-1/31/23. Weight loss noted post hospitalizations. Continues on, dialysis treatment 3/week. Plan: continue with current diet plan of care. Diet appropriate. There is no documentation noting V11 RD was notified of weight loss in one month. There is no documentation noting R3 was hospitalized since January 2023 to explain weight loss. Review of this facility's weight assessment and intervention policy, dated 2020, notes weights are monitored monthly or more often to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Nursing staff will record the resident weight the day they move in, the next day, and once a week for 4 weeks to establish a base weight and stability of weights. Weights shall be recorded in the resident's health record. Interventions for undesirable weight loss shall be based on the nutrition and hydration needs of the resident and the use of supplementation. Review of this facility's hydration monitoring policy, dated 2020, notes residents at risk for dehydration will be identified using the dehydration risk assessment and nutritional screening assessment. Fluids consumed at meals will be documented in addition to meal intake. The nutritional assessment shall reflect factors that put the resident at risk for dehydration as well as interventions to reduce risk factors and ensure adequate fluid intake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their Fall Prevention Program by not implementing appropriate fall interventions to provide necessary supervision for 1 (R357) of 4 residents reviewed for falls in a sample of 30. This failure resulted in R357 falling out of bed unwitnessed on [DATE] at approximately 4:30am and was found on the floor with a head laceration, went into cardiac arrest in the ambulance enroute to the hospital, arrived in the emergency room (ER) as a traumatic cardiac arrest, was found hypoxic with left sided atelectasis, and was pronounced expired at 7:57am with acute respiratory failure due to mucus plug with occlusion of trachea as the cause of death. Findings include: A review of R357's clinical records revealed R357 was initially admitted in the facility on [DATE] and was re-admitted from an acute hospital on [DATE]. R357's listed diagnoses are not limited to acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, dependence on respirator [ventilator] status, cognitive communication deficit, weakness, other lack of coordination, and bipolar disorder. R357's physician order sheet (POS) shows R357 was on high-risk psychotropic medication Seroquel 100mg given at bedtime. R357's admission Minimum Data Set (MDS) with assessment reference date (ARD) of [DATE] shows R357 required extensive one staff assist in bed mobility and toileting. R357's Fall Scale Evaluation dated [DATE] shows R357 was at moderate risk for falling. R357's Fall Scale Evaluation dated [DATE] shows R357 was at low risk for falling. R357's comprehensive care plan that was initiated on [DATE] shows R357 is at risk for fall R/T Deconditioning and impaired gait with only these interventions that read in part: Keep call light and desired personal items within reach and Maintain bed in lowest position. R357's Fall incident report dated [DATE] at 4:30am documented by V47 (Agency Nurse) reads in part, Resident observed laying on right side of face near trach accessory tubing. Pool of dark red blood noted under resident. Resident laying with head near right side of the wall next to bed. Feet near foot of bed. Bed in lowest position. Resident opens eyes to verbal command. Resident unable to state what happened. Periods of drowsiness noted. 4 cm laceration noted to forehead. R357's progress note documented by V42 (Respiratory Therapist) dated [DATE] at 7:28am reads, Around 4:40am called to room by nurse. Observed patient/pt on floor, vent alarmed. Both nurses & RT in room, Trach checked, it was patent and tubing intact. Nurse took vitals, and recorded SPO2 87% and began bagging pt with 100% oxygen. She had altered mental status. 911 was called, pt out to hospital. Facility's fall incident investigation on R357 documents in part: A witness statement from V61 (Certified Nursing Assistant/CNA) documents R357 on [DATE] was observed getting back into bed without assistance from using bed side commode. A witness statement from V45 (Certified Nursing Assistant) dated [DATE] documents that R357 was last seen at 2:30am while rounding and R357 was observed getting back into bed from using the bedside commode unassisted. A witness statement from V47 dated [DATE] documents at 4:30am V47 noticed R357's call light/ventilator alarm were sounding. V47 went into R357's room and observed R357 on the right side of R357's bed. A review of R357's Emergency Department (ED) triage notes dated [DATE] at 5:44am reads in part, Pt came from nursing home due to fall. Pt has a left sided facial laceration. Pt lost pulse while in ambulance. Emergency Medical Services/ EMS began CPR (no epis given). Trauma at bedside. Pt has a trach and is chronically vented. A review of R357's ED provider notes dated [DATE] at 9:06am revealed R357 was brought in as a traumatic arrest and initially managed by the trauma team. R357 reportedly fell out of bed at the nursing home and was found on the floor with a head laceration. R357 went into cardiac arrest in the ambulance enroute to the hospital. R357 arrived as a traumatic cardiac arrest and was found hypoxic with left sided atelectasis. R357 was pronounced dead at 7:57am. A review of R357's death certificate dated [DATE] shows acute respiratory failure due to mucus plug with occlusion of trachea as the cause of death. On [DATE] at 11:44am, V10 (Registered Nurse 2nd Floor Manager) was interviewed and stated that R357 was high risk for falling. V10 stated that R357 used the bedside commode for toileting and needed one staff assistance. V10 stated that at times R357 would get up without assistance and forgets to call for help when needed. V10 stated that R357 had no bed alarm. At 12:02 pm, V38 (Certified Nursing Assistant) was interviewed and stated that V38 had taken care of R357 while in the facility. V38 stated that R357 gets confused at times and would get up by herself but was not supposed to. V38 stated that R357 would sometimes forget how to use the call light. V38 stated that R357 was using a bedside commode for toileting needs and was doing it by herself but was not supposed to because it was not safe for R357. V38 stated R357 needed assistance with incontinence care. At 12:13pm, V9 (Respiratory Therapist) was interviewed and stated that R357 was on a full support ventilator and was very, very anxious. V9 stated that respiratory therapists (RTs) and the nurses should be monitoring the residents' ventilators. V9 stated that if the ventilators are not working properly, it would alarm. On [DATE] at 7:16am, a phone interview conducted with V42 (Respiratory Therapist). V42 stated that V42 was the RT assigned to R357 on [DATE] until 7:00am. V42 stated that R357 did not sleep that night. V42 stated that at around 4:00am, a nurse called V42's attention to R357's room because R357 fell from the bed. V42 stated, I saw [R357] was bleeding on [R357] forehead. On [R357] middle forehead. [R357] was lying on [R357] right side on the floor by [R357's] bed. I immediately checked the vent. The tubing was not disconnected. The nurse turned [R357] and cleaned the [R357], I checked the vent it was working properly and no other issues. [R357] right hand was lying over the trach tubing. I removed the hand from the tubing. [R357's] saturation was near about 94%. Nurse called 911 right away within 10 mins they came. [R357] was okay when 911 picked [R357] up. [R357's] heart rate was up but [R357's] saturation was 94-96%. At 11:18am, a phone interview conducted with V45 (Certified Nursing Assistant) and stated that V45 was the CNA in-charge of R357 from [DATE] night shift until [DATE] in the morning. V45 stated that V45 was on break when R357 fell out of bed. V45 stated that V45 went on break from 2:30am and came back at 5:00am. V45 stated R357 needed limited assistance from staff to use the bedside commode. V45 stated that R357 was on her (R357) phone all night that night. V45 stated R357 used the call light if needed but sometimes forgets and would get up by herself. At 11:36am, V2 (Director of Nursing) was interviewed and stated that fall risk assessment are done on resident's upon admission and after a fall. V2 stated that fall a care plan is initiated on admission and updated if there is a fall and based on the MDS calendar. V2 stated that fall interventions should be based on the nursing assessment and the resident's history. V2 stated that R357 came back from the hospital on [DATE] and R357's fall care plan was not revised. V2 stated that an appropriate fall intervention for R357 would be to remind R357 to call for assistance unless R357 was strong enough as far as therapy goes, but these were not indicated in R357's fall care plan. V2 stated, As far as I'm aware the staff did not let [R357] use the commode on her [R357] own but [R357] was observed not calling for help and staff would re-direct every time when they see [R357] transferring on her [R357] own. Surveyor asked V2 to provide documentation indicating education and re-direction were provided to R357. V2 stated that the education and re-direction were done verbally and would not be documented. On [DATE] at 11:49am, interviewed V33 (Staffing Coordinator) and stated that nursing staff can go on break for 30 minutes and a 15-minute quick break but not at the same time. V33 stated that more than an hour break is not acceptable. At 2:11pm, a phone interview conducted with V59 (Nurse Practitioner), V59 stated V59 took care of R357 while in the facility. V59 stated that R357 had tracheostomy and was too anxious. V59 stated that R357 had the tendency to not call for help when needed. V59 stated that R357 had a decline with R357's debility and needed more assistance. V59 stated that R357 fell, was sent out to the hospital, and expired. V59 stated V59 does not know R357's cause of death. Surveyor asked V59 that if a resident is on full support ventilator, fell with head trauma and wound development could that be contributory factors for a resident to have acute respiratory failure. V59 answered, Yes definitely. At 3:33pm, V50 (MDS/Care Plan Coordinator) was interviewed and stated that fall risk assessments are done first upon admission and the care plan should be implemented based of that, if the resident has history of fall, on psychotropic medications, and based on what type of assistance the resident needs. V50 stated that the resident's comprehensive care plan should be completed up to 21 days from admission. V50 stated that if a resident is at risk for falling and has the tendency to get up without assistance and is not supposed to, that problem should be included in the fall care plan. V50 stated that the care plan interventions should include based on the resident's risk factors that have been identified based on resident's assessment, staff observations, fall assessment, review of records, and resident and family interviews. V50 stated that the care plan should address what the staff assess from the resident because the purpose of the care plan is to guide the plan of care of the resident. V50 stated that the care plan is also used for communication so the staff would know what the needs, preferences, and concerns of the resident are. V50 stated that care plan interventions should be implemented based on what the staff establish from the resident, and it would be specific based of whatever the concerns of the resident are. V50 stated, If it's a fall care plan the interventions should be based on whatever the problem of the resident. It should include something that we know of about the patient. V50 stated that if the care plan is incomplete, the staff might not be able to adequately decrease the risk of the resident from falling and the staff won't be able to know the plan of care of the resident. V50 further stated that the resident's care plan should also be reviewed upon re-admission. Surveyor called V47 and left messages on these dates and times but to no avail: [DATE] at 7:12pm, 11:28am; and [DATE] at 7:40am and 3:20pm. V47 was the agency nurse in charge for R357 when the fall incident happened. The facility's policy titled; Fall Prevention Program revised on [DATE] reads in part: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Standards: Safety interventions will be implemented for each resident identified at risk. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. The facility's policy titled; Comprehensive Care Plan revised on [DATE] reads in part: Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to prevent an injury of unknown origin for 1 of 3 residents (R19) reviewed for abuse. This failure resulted in R19 having multiple unexplained bruises under the left eye, left shoulder and left forearm. Findings Include: On 11/30/22 at 10:16am, V67 (R19's family member) stated, R19 mouthed and pointed to V3 (certified nursing assistant/CNA), stating you hit me when V3 walked into the room on 11/24/22. R19 accused V3 (CNA) of hitting her in the face and pinching her. The incident had to happen on 11/23 when I didn't visit. I spoke to V3. V3 stated, I did not hit R19. I would never hit R19. I love R19. I would never hurt R19. V16 (respiratory therapist) told me, R19 eyes looked swollen. I reported it to V4 (nurse). V79 (emergency medical technician/EMT) stated, R19 had a black eye. I told R19 we couldn't prove the abuse but R19 keeps reporting the same thing. V3 is usually nice and takes care of R19 but something must have happened because R19 kept mouthing and writing V3 abused her. On 12/01/22 at 11:10pm, V69 (R19's family) stated, R19 had a black eye. V68 (R19's family member) stated, R19's right eye was red and puffy. R19 said, V3 did it. On 12/01/22 at 12:39 pm, V79 (EMT) stated, R19's face was bruised up on both sides. Right side face was bruised, left cheek circular 1cm bruise area. On 12/6/22 at 3:00pm, R19 was assessed to be alert and oriented to person, place and time. R19 stated V3 (CNA) started hitting(slapping) pinching me two weeks after I arrived at the facility. I didn't tell anyone because I was afraid V3 was going to retaliate. V3 would get upset because I would push the call light. V3 slapped my hands, both sides of my face and pinched my stomach. R19 demonstrated where and how she was being hit and pinched by making a pinching motion over her stomach (lateral right side) and a slapping motion to the back of the hand and face on both cheeks with the front/palm-side of her hand. R19 was observed with two dissipating red circular spotted areas under R19's eye bags (puffy areas under R19's bilateral eyes on the lateral side). R19's left lateral eye was observed with a dissipating blue crescent area similar to the shape of a crescent moon under R19's left eye bag/puffy area. R19 had a bruised/dissipating blue irregular shaped area on the left shoulder the size of a 5-cent coin, and a larger blue dissipating area that covered R19's bicep with two circular dissipating blue circular area underneath the bicep just above the antecubital space and a dark irregular square shape on the posterior arm located at the base of the tricep above R19's elbow. Hospital paperwork dated 11/25/22 documents: Diagnosis: Suspect Elder Abuse. Skin: Bruising present. When ask is she (R19) felt scared to return to her nursing home. R19 nodded her head yes. Abuse Policy: Facility abuse prevention program policy revised 1/22/19 documents: It is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and crime against a resident in the facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, means the individual must have intended to inflict injury or harm. Physical abuse: hitting, slapping, pinching, kicking, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Braden score dated 8/6/22 documents: R9's score as 12 which indicates high risk for acquiring pressure wounds(range 10-12) due to sensory (slightly limited), moisture (very moist), activity (chairfast), mobility(very limited) nutrition (probably inadequate) and friction/shear (problem). Preventive recommendation: Moisture-none. On 11/3/22 at 9:58am, V82 (R9's family) stated, R9 would call me on his mobile phone, ask me to call the nursing station so R9 could be cleaned after a bowel movement. R9 had to wait two hours to be cleaned. On 11/22/22 at 3:56pm, V58 (wound doctor) stated, R9's moisture associated dermatitis (MASD) was related to R9 being incontinence. R9 was left in feces and urine every two hours. When R9 was repositioned every two hours he was soiled. On 11/22/22 at 4:17pm, V58 said, an adult brief can worsen an area with MASD. The adult brief can dig into the impaired skin. On 11/22/22 at 4:27pm, V7 (wound nurse) stated incontinence can cause MASD. On 11/23/22 at 10:30am, V59 (wound nurse practitioner) stated, R9's skin etiology started off as moisture associated dermatitis. With constant moisture of the skin and exposed/impaired skin being traumatized by the adult brief can lead to subcutaneous tissue being loss. R9's wound picture dated 8/17/22 was observed with slough. R9's wound should have not been classified a MASD but as full thickness loss (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) I would have debrided R9's wound and packed it depending on the depth after the debridement. Wound assessment dated [DATE] documents: R9 had bilateral thighs moisture associated dermatitis which was facility-acquired. Clinical stage: Partial Thickness (Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough.) Wound doctor assessment dated [DATE] documents: Wound #4 Right thigh is a MASD, measurements are 10cm length x 0.5cm width x 0.1cm depth (LxWxD), with an area of 5 sq cm and a volume of 0.5 cubic cm. Wound doctor assessment dated [DATE] documents: Wound #5 Left thigh is a MASD, measurements are 10cm length x 0.5cm width x 0.1cm depth (LxWxD), with an area of 5 sq cm and a volume of 0.5 cubic cm. Care plan revised on 8/17/22 documents: Bilateral Thigh- MASD- incontinence care as needed, and skin barrier applied and turn and reposition. Based on interview and record review, the facility failed to immediately report and remove an elastic band from around one residents' legs which was placed by a family member. The facility failed to monitor a resident in respiratory distress, notify the physician to obtain treatment orders for a critical high white blood cell count, failed to identify/notify the physician to obtain treatment orders for an alteration in skin around the implanted venous port and failed to implement interventions to prevent skin breakdown from moisture associated dermatitis. These failures affected 4 of 4 residents (R15, R4, R16, and R9) reviewed for quality of care. These failures resulted in R15 developing blisters to bilateral lower extremities, R4 being treated for elevated white blood cells for 3 days and being transported to the local hospital to be evaluated, diagnosed, and treated for sepsis. These failures also resulted in R16's implanted venous port dehiscence and R16 having to be transported to the local hospital and R9 developing full skin thickness skin loss. Findings include: R15 was admitted to the facility on [DATE] with diagnoses of Anoxic Brain Damage, Acute Respiratory Failure, Dysphagia, Gastrostomy, and Tracheostomy. R15's emergency service report dated 11/6/22: Emergency Medical Service (EMS) crew was dispatched to patient location for trouble breathing. Upon arrival the EMS crew found patient alone in room with no nursing staff present. Patient appeared to be aspirating on liquid food, heavy wheezing and posturing. Nursing home respiratory therapist came into the room and stated that patient was suctioned at approximately 4:00am this morning and patient was not in distress. The respiratory therapist suctioned R15, while suctioning was taken place EMS crew noticed R15's legs were bound by a rubber band across both legs. At no point during patient care at bedside did a nurse come into the room. The EMS crew only received information from the respiratory staff and face sheet. History and vital signs taken advanced life support (ALS) care started. After suctioning EMS crew bagged patient with bag valve mask and patient's oxygenation levels improved from 71% to 97%. ALS care continued. Patient loaded into ambulance where ALS care continued. On 11/9/22 at 11:15am, V26 (fire department personal) state he responded to 911 call for R15. V26 stated when they arrived to R15's room there were no staff monitoring or attending to R15. The respiratory therapist came in the room shortly after they arrived and assisted with suctioning the patient. V26 stated upon transferring R15 to the stretcher, EMS observed R15's lower legs were bound with a black elastic band on bilateral thighs above the knees. The band appeared to be indented into R15s skin. The elastic band was removed by EMS and reported to facility staff. R15's hospital record dated 11/6/22 documents: EMS stated that upon arrival, the patient's legs were bound with physical therapy band. They report the nurse did not show up when they arrived. Under Emergency triage notes: Per EMS upon arrival patient was in severe respiratory distress with oxygenation at 78% on trach collar. EMS states patient condition was extremely poor. EMS also states patient had a resistance band around her thighs binding them together. R15's legs observed with red welts with blistering from where patient was restrained. On 11/16/22 at 10:50am, R15 was observed in bed. Resident legs observed to be contracted in a butterfly pose. R15's Bilateral arms and hand contracted to the body. There were several small open and scabbed areas on right upper leg and one scabbed area noted to left upper leg. On 11/17/22 at 11:11am, V65 (R15's family) stated she saw R15 around 10:00am on 11/5/22. V65 stated she placed the band around R15's legs to help exercise but her ride arrived early. V65 stated, there was a CNA on the other side of the room assisting with care to the roommate and she asked her to remove the band from R15. V65 stated she then left. On 11/9/22 at 305PM, V21 (CNA) identified as CNA for R15 on 11/5/22 7:00am-3:00pm shift. V21 stated she did not observe the band on R15 when she provided morning care. V21 said she recalls family visiting R15 in the morning and after they left V21 said she observed the band on R15's legs when providing care. V21 said she did not report it to anyone because she thought it was supposed to be on R15. On 11/10/22 at 312PM, V21 said that no one asked her to remove the bands from R15. On 11/9/22 at 3:48pm, V29 (CNA) stated she worked with R15 for the evening shift (3pm-11pm) and overnight shift (11pm-7aam on 11/5/22 into 11/6/22. V29 stated she observed the band on R15's legs during her shifts and stated she was able to provide incontinence care with no concerns. V29 stated she reported the band to V28 ( nurse) at the end of her first shift and the nurse just said okay. V29 stated the nurse did not give any further instructions and assumed the band was meant to be there. V29 stated she assumed other people had seen the band. V29 stated she saw blisters on R15's knees. On 11/22/22 at 2:26pm, V55 (CNA) stated she was the CNA working the 11pm-7am shift on 11/5/22 into 11/6/22 . V55 stated she heard V29 (CNA) asking the nurse about the bands on R15 and why were they there. V55 stated there was no response from the nurse. On 11/9/22 at 2:16pm, V28 (nurse) was identified as the nurse working with R15 11pm-7am shift on 11/5/22 into 11/6/22. V28 stated around 7am she went to give R15's morning medications and observed R15 in distress. R15 had emesis and pulse oxygenation was in the eighties. V28 stated she yelled for oncoming nurse who called 911 and the respiratory therapists, they were trying to clear R15's airway. V28 stated she stepped away to get R15's paperwork. V28 said she did not observe the band on R15 and said no one reported to her about the band on R15's legs. On 11/10/22 at 11:37am, V19 (Respiratory therapy, RT manager) identified as RT working with R15 on 11/5/22 into morning of 11/6/22. V19 stated she was performing change of shift report with V63 (RT) when she observed paramedics exiting the elevator on R15's floor. V19 stated she was not made aware that R15 was experiencing respiratory distress prior to EMS arrival. V19 said V28 (Nurse) was at the nursing station and reported that R15 was having a change in condition. V19 stated they went with EMS to R15's rooms. V19 stated she is unable to recall if any other facility staff were present in the room with R15 at time of EMS arrival to R15's room. V19 stated R15 was in distress and suctioning was performed. R15's oxygenation was 79% on 5 liters of oxygen. We increased oxygen to 15 liters and pulse ox went up to 91%. V19 denies seeing any bands on R15's legs. On 11/10/22 at 2:43pm, V34 (restorative aide) stated R15's family showed her the bands back in October. V34 stated she told the family the bands were not appropriate and no further discussion. V34 said she reported it to V35 (restorative nurse). On 11/10/22 at 238pm, V35 (restorative nurse) stated she spoke to R15's family in October. V35 stated family had inquired about placing bands on R15's legs due to contractures. V35 said she told family facility could not place bands on R15 because it would be a restraint and family said okay. There was no further discussion about the bands. V35 stated the conversation was documented on a on grievance form. Review of R15's medical record did not document any education or discussion with family about the use of bands around her legs. Review of facility grievance binder for September and October did not document any grievance related to R15. R15's wound assessment report dated 11/12/22 documents: right lateral knee; blister measuring 18x13x0.10cm; left anterior thigh; blister measuring 1x1xunknown cm. R4 was admitted to the facility on [DATE] with a diagnoses of Respiratory Failure, Protein-Calorie Malnutrition, Chronic Kidney Disease, type II Diabetes, Pressure Ulcer and Anemia. R4's progress note dated 10/19/22 at 11:36am documents: Spoke local hospital who stated that resident was evaluated, and they found no emesis when assessed. Resident noted to have elevated white blood count and chest x-ray was clear per emergency room (ER) nurse. Resident will not be admitted and will return back to facility. R4's progress note dated 10/20/22 at 1:19pm documents: R4 had emesis times(x)3. Vital signs stable. New orders for x-ray. R4's Physician order sheets documents order 10/20/22 referral for Gastroenterologist and stat KUB for vomiting. R4's laboratory results dated [DATE] documents: white blood count of 28.7. Results phoned and faxed on 10/21/22 at 1:47pm. Normal white blood cell count range is 4.8-10.8. R4's laboratory results dated [DATE] document white blood cells 14.7. R4's progress note 10/22/22 documents: Writer called patient's primary doctor to relay critical labs; could not reach MD; writer will pass labs onto the next shift nurse to recontact MD. R4's progress note 10/23/22 at 5:58pm documents: This writer left message with the on-call number to relay labs, awaiting call back. R4's progress note 10/23/22 at 8:05pm documents: Note Text: Lab results were relayed, MD gave orders to monitor. R4's progress note 10/24/22 at 3:56pm documents: V61 gave orders for patient to be seen by infectious disease for elevated white blood count. R4's Physician order sheets documents order on 10/24/22 referral for infectious disease. There were no other orders documented related to high [NAME] blood count. R4's medication administration record for October 2022 does not document any new treatments after 10/19/22. R4's vital signs were monitored once a day. R4's hospital record dated 10/24/22 documents: [NAME] blood count of 46.7. Under clinical impression documents: Sepsis due to unspecified organism and pneumonia due to infectious organism in part of the lung. R4's care plan dated 9/16/22 documents R4 has potential to exhibit signs and symptoms of infection related to chronic leucocytes. History of C.Auris fungemia, Enterococcal Bacteremia and Klebsiella; recent history of urinary tract infection. Interventions: assess for signs and symptoms of infection. Notify the physician as indicated; notify physician of change in condition; obtain laboratory results as ordered. Report abnormal reports to physician; obtain vital signs as ordered. On 11/23/22 at 9:45am, V60 (MD) and V61 (NP) stated they both do not recall being notified of any abnormal lab results for R16. V60 stated if he was notified of results, they would have monitored the patient. When asked to explain what monitor means, V60 said he would expect the staff to monitor R4's vital signs every shift and report any changes or abnormal values. V60 said any further interventions would depend on how the patient was presenting clinically and if no changes presented, they would just continue to monitor the patient. When V60 was asked if any additional diagnostic test should have been ordered, V60 replied that it was too soon to reorder CBC and he has never had any issues with laboratory results in the past. V60 said he may have ordered a blood culture but that takes a few days so it would have been easier to send the patient to the hospital at that point. V60 stated they did order KUB to be performed due to emesis and there were no findings. V61 stated she referred R16 to infectious disease on 10/24/22 prior to hospital transfer. On 11/22/22 at 2:53pm, V2 (DON) stated facility staff should notify the physician immediately for any critical lab results. If doctor is not available, they would reach out to the medical director to report results. On 11/23/22 at 9:39pm, V25 (Medical director) stated If she or her staff would have been notified of high WBC results, staff would have ordered additional labs for following day, possibly order chest x-ray, urine collection, blood cultures and reach out to infectious disease. V25 stated an elevated [NAME] blood cell count can led to sepsis if not treated. R16 admitted in the facility on 9/27/22 and was discharged on 11/1/22. Hospital record of R16 reviewed upon initial admission to the facility dated 9/27/22, under past surgical/procedure shows IR CVA Port Insertion on 8/29/22. R16 went for chemotherapy appointment on 11/1/22. Facility documentation dated 11/1/22 reads in part: Call received from nurse at appointment, per nurse stated that R16 would be admitted to hospital thru ER (Emergency Room) due to R16's current status. Nurse was not able to give admitting diagnosis. Per nurse R16 was noted with low blood pressure, R16 noted with complications to port a cath site upon removal of dressing. Hospital record dated 11/1/22, R16 presented in the hospital with tachypnea, hypoxic and dehiscence implanted port. R16 was found unresponsive while still in the ER and then admitted in MICU (Intensive Care Unit). On 11/16/22 at 1pm, V5 (Unit Manager) stated I believed R16 was in his appointment and the clinic informed me that R16 will be admitted to the hospital from his appointment due to blood pressure being low and complication with the porta cath. If I don't put it on my notes, I do not recall what was the venous port complications. I was not present when R16 left for R16's appointment and I just received a call when the nurse from the clinic had called to inform us that R16 is going to the hospital. On 11/17/22 at 11am, V28 (Oncologist Personnel) stated R16 was in our office on 10/7/22 and the porta cath site was fine, and on 11/1/22 appointment, we saw a band aid covering the port cath site. Removed it and noted the skin around the port has deteriorated. Skin surrounding the port is open and you can see the port. The site is clean and no bleeding, so I assumed someone from the facility is aware about the site and had cleaned it and put a band aid over it. R16 was sent to the hospital because of this skin opening surrounding the port. They are high risk of infection, for anyone with port implanted on them. On 11/17/22 at 10am, V2 (DON) V5 did not report to me or if V5 did, I dent remember if V5 reported to me R16's conditions when the oncologist office called that day. For any new skin alterations. We notify the doctor, family and the wound care team. They have to document new skin alteration and must be assessed to have proper treatment. Wound care team need to evaluate new skin alteration. On 11/18/22 at 10:30am, V7 (Wound Nurse) stated that R16 was admitted with skin breakdown to his sacral, unstageable. Sacral skin alteration healed before R16 left the facility, healed on 10/28/22. I did not know any other skin issues with R16 besides the sacral site that healed in October. I am not aware of any skin opening on his chest implanted port site. My expectation is for the staff to notify the doctor, family and the wound care team. It would be a concern to me if the port site is open, implanted port site is expected to be under the skin, with the skin intact. With skin opening around the port site, it should have a treatment order to prevent further complications. R16's facility physician order sheet reviewed and there is no noted order for any treatment for implanted venous port skin alterations. R16's progress notes reviewed from admission 9/27/22 to 11/1/22, and there is no noted wound/skin alteration related to the implanted venous port site/area. R16's TAR (Treatment Administration Record) did not show any treatments for skin alteration related to implanted venous port site/area. Facility policy titled Pressure injury and skin condition assessment revised 1-17-18 documents: Each resident will be observed for skin breakdown daily during care and on assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify a physician of a critical high white blood cell count result for one resident (R4) of three residents reviewed for abnormal labs. This failure led to a delay in care that resulted in R4 being transferred to the hospital with a diagnosis of Sepsis. Findings include: R4 was admitted to the facility on [DATE] with a diagnoses of Respiratory Failure, Protein-Calorie Malnutrition, Chronic Kidney Disease, type II Diabetes, Pressure Ulcer and Anemia. R4's laboratory results dated [DATE] documents: white blood count of 28.7. Results phoned and faxed on 10/21/22 at 13:47pm. Normal white blood cell count range is 4.8-10.8. R4's laboratory results dated [DATE] document white blood cells 14.7. R4's progress note 10/22/22 at 6:50am documents: Writer called patient's primary doctor to relay critical labs; could not reach MD; writer will pass labs onto the next shift nurse to recontact MD. R4's progress note 10/23/22 at 5:58pm documents: This writer left message with the on-call number to relay labs, awaiting call back. R4's progress note 10/23/22 at 8:05pm documents: Note Text: Lab results were relayed; MD gave orders to monitor. R4's progress note 10/24/22 at 3:56pm documents: V61 gave orders for patient to be seen by infectious disease for elevated white blood count. On 11/23/22 at 9:45am, V60 (MD) and V61 (NP) stated they both do not recall being notified of any abnormal lab results for R16. V60 stated if he was notified of results, they would have monitored the patient. When asked to explain what monitor means, V60 stated he would expect the staff to monitor R4's vital signs every shift and report any changes or abnormal values. V60 continued by stating any further interventions would depend on how the patient was presenting clinically and if no changes presented, they would just continue to monitor the patient. When V60 was asked if any additional diagnostic test should have been ordered, V60 replied that it was too soon to reorder (complete blood count) CBC and he has never had any issues with laboratory results in the past. V60 stated he may have ordered a blood culture but that takes a few days so it would have been easier to send the patient to the hospital at that point. V60 stated they did order (kidney, ureter, bladder) KUB to be performed due to emesis and there were no findings. V61 said she referred R16 to infectious disease on 10/24/22 prior to hospital transfer. On 11/23/22 at 10:26am, V60 (MD) stated he reviewed the on-call service report and there was no call received by the facility during the time documented in the progress notes by the facility. On 11/22/22 at 2:53PM, V2 (DON) stated facility staff should notify the physician immediately for any critical lab results. If doctor is not available, they would reach out to the medical director to report results. On 11/23/22 at 9:39am, V25 (Medical director) stated she does not recall being notified of critical laboratory results for R4. If she or her staff would have been notified of high WBC results, staff would of ran additional labs for following day, possibly order chest x-ray, urine collection, blood cultures and reach out to infectious disease. If no of those things are documented, we may not have been notified of results. Facility policy titled Physician - Family notification- change in condition revised 11-13-18 documents under purpose: to ensure that the medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient and effective manner. The facility will inform the resident, consult with the resident's physician or authorized designee such as nurse practitioner, notify the residents legal representative when there is: a significant change in the resident's physical, mental or psychosocial status. A need to alter treatment significantly.