**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident remained free from staff to resident abuse for one of three residents (R1) reviewed for abuse. This failure resulted in R1 sustaining physical injuries and R1 being transported to the emergency department for treatment, ultimately resulting in R1's request discharge against medical advice due to fear and dissatisfaction with the facility. R1 is a [AGE] year-old with diagnoses including heart failure, epilepsy, hypertension, hyperlipidemia and anxiety disorder. On 7/18/25 at 1:50 PM, V1 (Administrator) said she was the abuse prohibition coordinator and was present in the building due to flooding in the basement that evening she was trying to address when V4 nurse had an altercation with the resident R1. V1 indicated she was told by the resident that V4 hurt his wrists and chest during the altercation and that the resident called 911 and police and fire department came to speak with resident. V1 said she personally walked V4 out of the building at around 8:30 PM to investigate the incident and that she had reviewed the facility security closed circuit television (without audio) but did not believe V4 was at fault however suspended the staff member to follow their abuse policy. V1 then offered to show the video surveillance to the surveyor. Facility security video footage (without audio) captured the incident. Although the verbal exchange could not be heard, the footage showed V4 pointing and motioning aggressively to R1 to return to his room. The video also showed physical interaction consistent with the R1's account, including a posture and mannerisms by the nurse (V4) suggestive of an aggressive and confrontational stance. The video footage further supported that the situation escalated instead of being diffused. V4 is seen motioning with his hands for R1 to come towards him whereupon R1 appears to dash down the hall with clenched fists and confronts V4. V4 appears to remain in place instead of walking away from the situation in order to diffuse further escalation. There appears to be a verbal exchange between V4 and R1. V4 again instead of walking away, appears to push R1 away from him and makes contact with the resident's chest and hands. V4 continues to make motions with his hands and points in the direction down the hall in an effort to tell the resident to go back to his room. The whole exchange lasted over 2 minutes whereupon the resident disappears from camera view and V4 returns to nursing station. On 7/19/25 at 3:30 PM, R1 said, a male nurse treated me like some dog. I asked him to go see what's going on with another female resident who kept screaming and screaming and she sounded like she was in a lot of pain, and no one was paying attention to her. I asked this male nurse to go help her and he shouts down the hall to me to quiet down and that it wasn't his patient and to go back to my room. This really upset me because he treated me like I was some mental patient, and this angered me. He kept arguing with me that it wasn't his patient and to stop telling him what to do. He motioned to me to come to him like I was some dog as if he wanted to fight me, so I did that and went over to him, but I didn't hit him or anything, but he was pointing his finger at me and kept motioning to me to get the hell away from him instead of addressing the situation. He pushed me away and that's when I think he hurt my chest, and I must have banged my elbow, but I was so angry that I can't really recall all the details. He's a nurse and should not treat patients this way so I told this when I was in the ER (emergency room.). R1 returned to the facility after treatment but expressed to staff the following day that he no longer felt safe and requested discharge against medical advice. R1 said he was being watched by V3 social worker and other staff and he was treated like an animal and wanted to go somewhere else instead where staff were kind. R1 stated R1 was trying to get another patient some help.On 7/18/25 at 3:30 PM, V3 (Social Service Director) said that he is involved in the orientation of new employees, but that part of his orientation does not include anything related to de-escalation of behaviors but more so a general summary of dementia and emphasis on elopement prevention. On 7/18/25 at 4:10 PM telephone interview, V4 (LPN) said that he did not have any physical contact with the resident and denied raising his voice to the resident. V4 said that R1 placed his chest against his chest and his arms were at his side and he tried to control himself. Surveyor asked what he meant by trying to control himself and asked if R1 made him angry, V4 said that he meant that he wanted to try to make the resident calm was what he meant to say but admits that he was unable to calm the resident down. Surveyor asked where his arms were when this altercation came about, V4 said that his arms were at his side all the time. Surveyor asked if he raised his voice, shout at the resident, or used any type of harsh language, V4 said that he told (R1) that the resident that was screaming was not his and that he had the resident to go back to his room numerous times, but the resident did not listen to him. V4 indicated he had past dementia training but not this current facility. V4 denied de-escalation training on resident behaviors. V4 indicated he was not shown the video. On 7/18/25 at 4:30 PM, V5 LPN said V5 was the other nurse on duty the night of the incident (7/16/25) did not witness the altercation between R1 and V4 as she was busy in another room attending to a different patient however heard a loud argument down the hall. V5 said she heard the resident (R1) screaming at V4 but did not hear V4 saying anything back to the resident. V5 said she heard an argument but only heard R1 shouting. V5 again said, that she heard R1 but said that V4 did not say anything to the resident. V5 stated V5 did not observe what was written in the note, No I was busy in another room. Review of V5's nursing note entry does not align with her statement to the surveyor. On 7/16/25 at 8:30 PM, V5 (LPN) wrote, R1 approached Nurse V4 (LPN) and requested that he check on another resident who was asking for help. Nurse V4 responded promptly and went to assist the other resident. Upon returning, Resident appeared upset and began yelling at Nurse (V4), demanding that he go back and check on the resident again. Resident became increasingly agitated and attempted to physically punch (V4). Nurse V4 raised his hand to block the punch. Nurse V4 then instructed R1 to return to his room and refrain from further aggressive behavior. Shortly after the incident, Resident alleged that Nurse V4 had struck him and requested that the police be contacted. Due to the escalation and the resident's emotional state, the decision was made to send R1 to the emergency room (ER) for further evaluation and safety assessment. Supervisor was notified.Facility abuse policy revised 2022 reads in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this guidance is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure for hydration and tube feeding tube care by not ensuring that a resident received the recommended amount of fluids for a resident who is dependent on tube feeding for nutrition. This failure applied to one (R1) of four residents reviewed for hydration and resulted in R1 being hospitalized with diagnoses including dehydration, high blood sodium, and hypotension (low blood pressure). Findings include: R1 is a [AGE] year-old male with a diagnoses history present on admission of Brain Damage due to Oxygen Deprivation, Bacterial Infection, Epilepsy, Congestive Heart Failure, Stage 4 Pressure Ulcers, Acute Kidney Failure, UTI's, Trach Use, and Feeding Tube Use who was admitted to the facility 07/27/2024. On 02/10/2025 at 10:29 AM Observed R1 in his room lying in his bed unable to speak, bed bound, and receiving a enteral nutrition via a tube feeding. R1's current care plan documents he has potential for impaired nutrition related to acute and chronic medical conditions, wound, being tube feeding dependent, and receives nothing by mouth with interventions including; registered dietitian to provide monthly nutrition assessment and evaluate fluid needs and adequacy/appropriateness of current feeding regimen, and report any early signs of fluid overload or dehydration to the physician for further medical evaluation. R1's Monthly Enteral/Skin Note created by V9 (Registered Dietitian) dated 11/01/2024 documents R1 was being readmitted from a hospitalization and was receiving an enteral flush of 30ml of every 4 hours with recommendations to increase his flush back to 200ml every four hours the new flush would provide 2297 ml of fluid. R1's physician order history includes an order effective from 10/31/2024 to 12/02/2024 for flushing his feeding tube with 30ml and of water every four hours. R1's November and December 2024 Medication Administration Records documents he was receiving a flush with 30ml of water every four hours from 10/31/2024 to 12/02/2024. R1's progress note dated 12/2/2024 08:02 Writer spoke with a Registered Nurse at the hospital and was notified that the resident's blood pressure remains severely low, and resident is dehydrated. R1's hospital record dated 12/02/2024 documents he was admitted to the emergency room from the nursing home due to significant hypotension, was evaluated and received a primary diagnosis of dehydration, and of high blood sodium and chloride and acute kidney injury; he was assessed on admission to be profoundly dehydrated with an acute renal insufficiency and high blood sodium and it was noted that he was likely hypotensive related to these diagnoses. 02/13/2024 at 1:12 PM V2 (Director of Nursing) reported that on admission there is a section of the admission assessment that addresses nutrition and the RD (Registered Dietitian), Nurse Practitioner, Physician's Assistant, and Physician are made aware of residents enteral feeding orders received from the hospital and the orders are reconciled on admission. V2 reported the RD then further evaluates the resident's needs, makes recommendations for changes to formula, volume and flushes, and labs are also ordered on admission and readmission. V2 reported labs are ordered and evaluated by the RD, Nurse Practitioner, Physician's Assistant, and Physician and the facility uses pumps for enteral feedings and flushes and these are to be signed off on Medication Administration Records. V2 reported a collaboration of nurses assessments, weights, labs, and RD/Nurse Practitioner/Physician evaluations and recommendations are used. 02/13/2024 at 2:23 PM V2 (Director of Nursing) stated after the RD (Registered Dietitian) makes a recommendation the nurses are to call the physician to see if they agree with the orders and the orders are changed if the physician agrees. V2 stated typically the RDs will put in orders if they change the actual feeding, and the nurses verify the orders so there is a two-step process. V2 stated once the nurse confirms the orders and the orders they are verified in the resident's medical chart under physician orders. V2 stated if a flushing order was needed for R1, and it was not entered it could affect his electrolytes and his hydration. V2 stated if R1 was not receiving enough fluids and the RD recommended an increase in flushes this could possibly cause dehydration because his urine output might decrease. V2 stated fluid intake for R1 is monitored by observing feeding tube flushes and how many cc's (cubic centimeters) of fluid he receives an hour through enteral feeding and his fluid output is monitored by observing whether there is a decrease in how many times he receives incontinence care, whether there is a urine odor, or if incontinence products used may become discolored because of urine concentration. R1's progress notes from 11/01/2024 - 12/02/2024 did not include any communication with his physician regarding V9's (Registered Dietitian) recommendations to increase his fluids as documented in her notes on 11/01/2024. 02/13/2024 at 4:10 PM V2 (Director of Nursing) stated V9 (Registered Dietitian) never submitted an order for R1's recommended fluid increase. V2 stated V9's progress note regarding this recommendation was originally entered into an inactive electronic health record system on 11/04/2024 and the note was never transferred to the electronic health record system that became actively used on 11/01/2024. V2 stated the facility was not aware of or notified of V9's recommendations to increase his fluids until 12/03/2024 when V9 provided this recommendation by email. V2 stated the facility reviewed Medication Administration Records for 24 hours after the transition of the electronic medical record system on 11/01/2024 however there was no order submitted by V9 for R1's fluid increase. V2 stated it was V9's responsibility to ensure the facility received the recommendation or order to increase R1s fluids and she should have communicated this information in real time. V2 stated the concern with V9's failure to ensure the recommendation was communicated or ordered is that R1 was not getting the amount of fluids he needed. V2 stated the physician was never notified of V9's recommendation to increase R1's fluids due to the missing communication from V9. The facility's Tube Feedings/Enteral Nutrition Policy received 02/11/2025 states: Objectives: to maintain the desired fluid status of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly transfer one resident (R1) and ensure that R1 was wearing proper footwear during the transfer. This failure resulted in R1 being hospitalized and sustaining a fracture to the neck. Findings include: R1 is an [AGE] year old female who admitted back to the facility on [DATE] and was discharged to the hospital on 1/10/2025. R1 has multiple diagnoses including but not limited to the following: type II DM, dementia, psychosis, HTN, dysphagia, difficulty in walking, unsteadiness on feet, disorientation, and need for assistance with personal care. V3's (Licensed Practical Nurse) progress note dated 1/5/2025 at 10:00AM states in part but not limited to the following: V4 (Certified Nursing Assistant) was transferring R1 from wheelchair to the shower chair. V4 said R1 began to slide and was lowered to the floor. R1 was wearing slippers at the time of transfer. On 1/15/2025 at 11:15AM, V4 said I was going to give R1 a shower. R1 was previously a resident here and I was familiar with her. However, this was the first time I had given her a shower since she returned. R1 can transfer independently. R1 was sitting in her wheelchair. I placed her walker in front of her, she stood up using the walker, and I attempted to move the wheelchair and replace it with the shower chair. During the transfer, R1 began to slip and slide down to the ground. She was wearing slippers and she seemed weaker than normal. I assisted R1 in sliding down to the ground. V4 said R1 did not need a transfer belt. A transfer belt is used when a resident cannot mobilize themself. R1 can transfer herself and only needs supervision. It is to be noted that per R1's care plan with initiation date of 12/26/2024 states in part: R1 requires substantial/maximal assistance with 1-2 person assistance to move between services. when transferring. Use gait belt with transfers. Per Minimum Data Set (MDS) dated [DATE] states in part but not limited to the following: R1 requires maximum assistance when transferring into the shower and when going from a sitting to standing position. On 1/15/2025 at 1:41PM, V2 (Director of Nursing) stated R1 required a gait belt when transferring and I would have expected V4 to use one during this transfer. R1 was also wearing her favorite red slippers which are not appropriate when transferring. R1 should have had non-skid socks on. Hospital records dated 1/10/2025 state in part but not limited to the following: R1 presenting to the emergency room after a witnessed mechanical fall. It is reported that the fall occurred while R1 was taking a shower. R1 was guided to the ground by nursing staff and V5 (family member) observed bruising today on the back of R1's head. CT impression shows an acute C7 spinous process fracture. On 1/16/2025 at 11:15AM, V7 (Primary Physician) said this type of fracture can occur from any sudden movement or a fall especially in the elderly. Fall Prevention and Management Policy with last review dated of 02/2023 states in part but not limited to the following: The purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualized, person-centered care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain a urine specimen from a catheter in a timely manner, document indwelling catheter output, ensure catheter care was provided and identify/respond to signs and symptoms of a UTI (Urinary Tract Infection) in a timely manner for 2 of 3 residents (R1, R3) reviewed for indwelling catheters in the sample of 3. These failures resulted in R1 requiring emergency treatment and hospitalization for a severe UTI with sepsis. The findings include: 1. The facility's Grievance Form dated 8/30/24 showed a representative from the Public Guardian's Office expressed concern regarding a phone call received by the emergency department. The ER (emergency room) informed them that R1 was admitted to the hospital with a sludged catheter. The back page of this form titled, Facility Grievance - Written Decision Form was blank. There were four sections including: Facility information, Grievance/complaint information; Investigation and Results; Was the grievance/complaint confirm (y/n); Resolution. All these sections were blank. R1's Face Sheet 9/29/24 showed diagnoses to include, but no limited to heart failure, chronic kidney disease (Stage 4), history or UTIs, dementia, diabetes, prosthetic heart valve, functional quadriplegia, neuromuscular dysfunction of the bladder, and presence of a chronic indwelling catheter. R1's facility assessment dated [DATE] showed she had severe cognitive impairment; had an indwelling catheter; was dependent on staff assistance for toilet hygiene and shower/bathe; and required substantial/maximal assistance with personal hygiene and bed mobility. R1's Physician Order Sheet dated 8/1/24 to 9/30/24 showed orders for UA (urinalysis), Reflex to Culture dated 8/8/24 and 8/13/24. It does not show an order for the UA ordered on 8/2/24 (per the facility's progress notes). This document showed orders for: Foley catheter care every shift and PRN and Document Foley output every shift. R1's August 2024 MAR (Medication Administration Record) showed Document Foley output every shift, there were no documented urine outputs for 3-11 and 11-7 shifts the entire month. The urine output was not charted 3 times for the day shift and 5 days the facility staff entered medium or large, instead of a volume of urine in milliliters (ml). This document showed R1's Foley Care every shift and PRN was not documented by 3-11 and 11-7 shifts the entire month of August and was not completed on 8/18/24 by the 7-3 shift. This document showed R1's Foley Catheter was changed on 8/11/24. R1's Progress Notes showed on 8/2/24 at 9:44 AM, R1's daughter visited and was concerned that R1 was crying, seemed more confused, and couldn't recognize family members. R1's daughter requested a urinalysis to check for a UTI. The writer notified V10 (R1's Physician) and obtained an order for a lab and a urinalysis. R1's Progress Notes dated 8/8/24 showed lab was called for the urinalysis results and the lab employee reported the urine specimen had not been collected. At 2:19 PM, the urine sample was collected and placed in the first-floor refrigerator for lab pick up. R1's Nurse Practitioner Note dated 8/8/24 showed she was seen for concerns with increased confusion. This document showed the resident slept through the entire visit but did not appear to be in pain or distress. This note showed that the urinalysis and labs ordered were discussed with the nurse. This note showed the indwelling catheter was draining clear yellow urine. R1's Progress Notes dated 8/12/24 showed the nurse called the lab to check on the urinalysis results and multiple bacterial morphotypes were found. The lab recommenced re-collecting a urine specimen. V10 was notified and orders were received to recollect the urine specimen. The nurse was unable to collect the urine sample from the indwelling catheter and reported to the next shift to obtain R1's urine specimen. R1's Progress Note on 8/28/24 by V2 (Director of Nursing/DON) showed R1's daughter called public guardian's office to have R1 sent to the ER. ADON (Assistant Director of Nursing) called R1's doctor (V10) to make him aware of the change in condition and poor appetite. The order to send R1 to the hospital was received. 911 was called. R1's Progress Note by V3 (ADON) was a late entry created on 8/30/24 at 5:45 PM (after R1's Guardian filed a Grievance with the facility). This note showed R1 was able to respond to commands, denied pain. Her family was at the bedside and vital signs were obtained. This note did not address the appearance of R1's urine. (There are no progress notes dated 8/28/24 by the V12 (Licensed Practical Nurse/LPN) that was caring for R1). R1's Progress Note dated 8/29/24 showed R1 was admitted to the hospital for a UTI. R1's UA collected on 8/8/24 showed R1's urine was cloudy yellow, had large leukocytes (white blood cells) and MANY bacteria. This report showed that multiple bacteria morphotypes were present (likely a contaminated specimen) and recommended re-collection of the urine specimen. There was no evidence of a urine specimen obtained by the facility from 8/2/24 to 8/7/24 (the first UA ordered was received 8/2/24 per to R1's progress notes), nor was there a urinalysis report after the 8/11/24 specimen report. R1's UA Report collected 8/13/24 showed R1 had cloudy, yellow urine. This report showed R1's urine contained Large leukocytes, had protein in it, MANY bacteria, had 11-20 HPF (Normal range is 0-5 HPF) Red Blood Cells and had 21-50 HPF (normal range is 0-5 HPF) [NAME] Blood Cells. R1's Lab Report showed on 7/24/24 R1's WBC (White Blood Cell Count) 5.95 and on 8/3/24 R1's WBC increased to 11.82 (Double the last result, indicating a possible infection). R1's Care Plan initiated 12/18/23 showed R1 was at risk for UTI related to history of UTIs. The interventions included, but were not limited to: Monitor for signs/symptoms of sepsis (fever, confusion, lethargy, elevated BP, tachycardia) and report to PCP (Primary Care Physician); Monitor lab work and report abnormalities; Provide peri-care as appropriate to decrease skin contact with moisture; and Report signs of UTI (acute confusion urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul order, concentrated urine, blood in urine) and notify MD as appropriate. R1's Care Plan initiated 10/14/21 showed R1 required a Foley catheter related to neuromuscular dysfunction of the bladder. The interventions included, but were not limited to: Monitor for complications related to catheter use such as catheter obstructions, bladder distension, and pain; Observe drainage (amount, type, color, odor); Provide catheter care daily and as needed; Report UTI (acute R1's emergency room records dated 8/28/24 showed R1 had a temperature of 99.9 degrees Fahrenheit; elevated lactate level (used to diagnose sepsis); elevated kidney function tests (BUN/Creat); elevated WBCs at 26.7 (normal range is 4.2 to 11 K/mcl). (This number is more than double the last WBC obtained at the facility on 8/3/24). This document showed R1 will respond to her name, but continues to say, Yes Lord, and will not answer any other questions. This document showed R1's urine was straw colored with sediment. This document showed that during ED triage, the family reported they called the ambulance because she was less responsive than normal and did not eat as much food as usual today. This document showed at 7:27 PM, the ED nurse spoke with the County Public Guardian regarding R1's condition. R1's Hospital Records dated 8/29/24 showed R1 presented with fatigue and AMS (altered mental status). This record showed R1's family visited her and noted that she was weaker than normal and was not eating/drinking. R1 appears disoriented. R1's CT of her abdomen and pelvis showed bladder wall thickening and perivesicular stranding that may represent acute cystitis (recommend correlation with urinalysis). This document showed R1 was diagnosed with acute toxic metabolic encephalopathy likely due to a CAUTI (Catheter Associated Urinary Tract Infection), sepsis, leukocytosis, and lactic acidosis. R1 was placed on intravenous antibiotics and was hospitalized from [DATE] to 9/5/24. On 9/30/24 at 3:04 PM, V18 (County Public Guardian) said R1 had a history of UTIs and had been in and out of the hospital. V18 said the ER nurse reported that R1 had sludge in her urine, and she was concerned with the appearance of the urine. V18 said that gave us concern for how the facility was taking care of R1's catheter. V18 said they had temporary guardianship of R1's financial and healthcare needs and they are responsible for ensuring R1's needs were met at the facility. On 9/29/24 at 12:12 PM, V5 (Registered Nurse/RN) said if a resident is having increased confusion or a change in their mental status, it could be a sign of a UTI or something else going on. V5 said the nurse should complete an assessment and call the doctor for orders. V5 said if a UA is order, it can be obtained for the indwelling catheter right away. The UA results are usually available within 24 hours, but the culture may take 2-3 days. The nurses can look in the chart to see if the labs are completed. V5 said a resident with an indwelling catheter should receive catheter care and urine outputs should be monitored every shift. The purpose of catheter care is to keep the area clean and reduce the risk of infections. V5 said the urine output is records and the nurses should be reviewing to see if there are any trends. V5 said the catheter care and urine output should be charted in the MAR. On 9/29/24 at 12:33 PM, V7 (LPN) said the nurses can collect a UA directly from the Foley catheter and it shouldn't take more than 24 hours to collect the specimen. The surveyor asked V7 if she remembered calling lab for the UA results on 8/8/24 and being told that the UA had not been collected. V7 stated, I don't remember, but if I documented it, then that's what happened. V7 said the nurse should document a volume of urine (in milliliters), not small, medium, large. V7 said we look at the urine output to ensure the catheter is working, the resident isn't having any health issues, and they are hydrated. V7 said the catheter care and urine output should be charted once a shift on the MAR. On 9/29/24 at 1:25 PM, V1 (Administrator) said on 8/30/24 the Grievance Form was completed because the Public Guardian's Supervisor came to the building and reported she was concerned because the ED nurse reported that R1's catheter was sludged. V1 said she assigned the investigation to V2 (DON). V1 said she wasn't sure why the back of the Grievance Form had been blank, and she would have to check with V2 (DON). On 9/29/24 at 1:37 PM, V3 (ADON) said the basic care of an indwelling catheter should include catheter care every shift; measuring the urine output every shift; securing the device; ensure its draining; and changing the catheter as needed. V3 said the resident should have orders for each item and the nurse should sign them off in the MAR as completed. This catheter maintenance is completed to reduce the risk of infections. V3 said an actual amount should be documented for urine output because there is no way to identify what small, medium, and large means. V3 said those should only be used for BMs and incontinence. V3 said the importance of measuring the urine output is to ensure the catheter is patent and monitor the resident's status. V3 said an increased WBC count shows there's possibly an infection. V3 said if a resident is experiencing fever, change in level of consciousness, poor appetite, changes in the color and clarity of the urine, then he would expect the nurse to call the doctor and obtain orders. V3 said the nurse should ensure the orders are completed. V3 said a UA can be obtained quickly from an indwelling catheter and the facility has a specimen refrigerator for storage. V3 said lab usually picks up specimens daily, Monday-Saturday. V3 said he was approached by R1's daughter on 8/28/24 and she said something was wrong with R1. V3 said he did not remember if he looked at R1's catheter, but he obtained vital signs from R1. V3 said 911 was called and R1 left for the ER with 5-10 minutes. On 9/29/24 at 2:30 Pm, V16 (Certified Nursing Assistant/CNA) said she was R1's CNA on 8/28/24. V16 said R1 wasn't acting like herself, she refused to eat breakfast. V16 said she reported it to R1's nurse, but she was an agency nurse and couldn't remember her name. V16 said R1 was screaming like she was in pain and that's not normal. V16 said the only time R1 normally screamed was during care. V16 stated, I told the nurse that too. But I didn't see the nurse go in there. Then her daughter came and asked if I saw her mom crying. I told her that she had cried most of the day. She didn't have much urine in her catheter, but she didn't eat or drink anything. She was definitely different. She is normally able to make her needs known, but she was more confused that day. She looked very tired and wasn't very alert. She was the same way at lunch. That's why I told the nurse again. I tried and tried. Her daughter called 911. On 9/30/24 at 11:11 AM, V12 (LPN) said she no longer worked at the facility, but she was R1's nurse the day she was sent to the hospital (8/28/24). V12 said she talked to R1's Guardian because R1's daughter insisted we sent her to the hospital. V12 said she doesn't remember any of the specifics, just that the daughter thought she was more confused than usual. V12 said she doesn't remember the exact time, just that she had gone on break and when she returned the Guardian called. V12 said the DON and ADON were there too. V12 said she didn't recall the CNA reported R1's poor appetite, crying, and not acting herself. V12 said she remembers giving R1 a pill and she took it fine. V12 said if she knew R1 wasn't eating, had an altered mental status, and was crying then she would have called the doctor. V12 said she didn't recall what R1's urine looked like. On 9/30/24 at 11: 25 AM, V9 (Nurse Practitioner) said the signs and symptoms of a UTI can vary with age. V9 said some possible side effects included: altered mental status, frequency, fever, dysuria, back/flank pain. V9 said if a nurse calls me because the family is concerned about increased confusion and requests a UTI, then I will discuss it with the nurse and usually order an UA. V9 said she expects the facility to collect a UA from a catheter quickly and results are usually available within 48 hours. V9 said the culture will take 2-3 days, but the UA results can be difficult to get/view through the facility's EMR. V9 said R1 is usually up in her chair and can carry on a conversation with her. V9 said R1 doesn't complain much and can tell the staff how she is feeling. V9 said the facility had in-house Providers that would give orders if resident's UA showed UTI and sometimes, she doesn't hear about the UA results until she is in to round on patients. V9 said it's a system that they are trying to improve. V9 said the facility has an in-house Infectious Disease Provider and a consult can be ordered right away. V9 said R1's WBCs doubling could have been a sign of a possible infection, but the providers are careful to not order antibiotics before the culture results. V9 said if she knew the UA had not been collected, R1 was having increased confusion, and the WBCs had doubled, then she may have ordered prophylactic antibiotics. V9 said she was not aware the UA collection was delayed. The surveyor asked V9 what increased confusion, crying, poor appetite, and poor urine output could demonstrate. V9 replied, All her symptoms are signs of UTI, septicemia, and possibly renal failure. I'm sorry to hear this about [R1]. This should have been addressed sooner. On 9/30/24 at 2:05 PM, V2 (DON) said the nurse on the floor is responsible for obtaining a urine specimen. V2 said it shouldn't take long to obtain a urine specimen from an indwelling catheter. V2 said if the resident had other labs ordered, then the nurse should try to collect the urine specimen before lab comes to draw the labs, so they can take it with them. V2 said the nurses are responsible for checking the EMR to ensure an order was entered, the specimen was obtained, the specimen was received by lab, and the results are relayed to the physician. V2 said this is done to catch a possible UTI as soon as possible and start treatment. The surveyor asked V2 what cause sludge in a catheter. V2 said it could be from a buildup of sediment or infection. V2 said catheter care every shift and monitor urine output every shift are part of routine catheter care and she expects it to be done every shift, as ordered. The surveyor asked V2 to review R1's MAR and asked why there were no 3-11 or 11-7 entries. V2 said she did not know. V2 said on 8/28/24 V3 (ADON) exited R1's room and said R1's daughter wanted her sent to the ED and she called the Guardian. V2 said she did not enter R1's room, nor did she assess R1. The surveyor asked V2 why R1's nurse (V12) did not document on R1's status 8/28/24. V2 replied, I don't know. There should be something in the legal documentation to show that something was done. She (V12) was terminated. V2 said she did not see a UA collected between 8/2/24 and 8/8/24. V2 said R1 had a catheter, and the nurse should have been able to collect a urine specimen as soon as possible. V2 said catheter care is done to protect residents from infection and can be completed by the nurse or CNA. The facility's Collecting Urine Specimen from Urinary Catheter Policy dated 2/2023 showed, Objective: To obtain a urine specimen from urinary catheter. Procedure: 1. Verify the order and assemble the supplies . 9. Urine specimens may also be collected by changing the Foley catheter and drainage bag. The facility's Catheter Care Policy dated 7/22 showed, Objective: 1. To cleanse the perineum. 2. To prevent infection and odors . 2. On 9/29/24 at 12:02 PM, R3 was sitting in his wheelchair, in his room, watching TV. R3 had catheter tubing extending from the bottom of his right pant leg. There was a large amount of brown/tan sediment noted in the catheter tubing. R3 said he's had the catheter for a while. R3 said he wasn't having any more problems with it, since they changed it last Friday. R3 said before that it was hurting him, and urine was leaking around the catheter. R3's Face sheet dated 9/29/24 showed diagnoses to include, but not limited to: COPD (chronic obstructive pulmonary disease); ataxia; anemia; bladder neck obstruction; retention of urine; obstructive and reflux uropathy; protein-calorie malnutrition; spinal stenosis; tremor; anxiety; congestive heart failure; and peripheral vascular disease. R3's facility assessment dated [DATE] showed he was cognitively intact; required substantial/maximal assist with personal hygiene; shower/bathe; and bed mobility; was dependent on staff for bed mobility and transfers; and had an indwelling catheter. R3's Physician Order Sheet showed he had orders to: Document urine output every shift and catheter care every shift and PRN (as needed). R3's September 2024 MAR showed 20 missing urine outputs and 31 entries that showed Small, medium, or large (not a volume of urine output). This document showed that R3's catheter care was not documented 8 times. R3's Urinalysis Report collected 9/3/24 showed R3's urine was cloudy, yellow, and contained nitrites, protein, MANY bacteria, RBCs, and >100 WBCs. R3's Care Plan initiated 9/9/24 showed R3 was on antibiotic therapy related positive urine culture for ESBL. R3's ID (Infectious Disease) Follow up Note dated 9/17/24 showed R3 was being seen for ESBL UTI and R3 had mild gross hematuria. On 10/4/24 at 12:23 PM, V2 (DON) said R3 was admitted to the facility with COPD, frequent UTIs, generalized weakness, and had an indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, this facility failed to provide the necessary services, identify a decline, implement interventions, and evaluate the effectiveness of interventions to prevent the decline in range of motion. This affected one of three residents (R1) reviewed for a decline in functional abilities. This failure resulted in R1 developing a contracture of right hand and is unable to extend fingers. Findings include: R1's medical record notes R1 with diagnoses including, but not limited to, tracheostomy, ventilator dependent, left knee contracture, gastrostomy, nontraumatic intracerebral bleed, stroke with hemiplegia affecting right side, cardiac arrest, generalized muscle weakness. On 12/26/23 at 9:18 AM, R1's family member stated that R1's hands are contracted because he is not receiving therapy. R1's family member stated that R1 is supposed to wear a splint on right hand, but she never sees R1 wearing it and now R1's right hand is contracted. On 12/26/23 at 1:30 PM, R1 was observed lying in bed without a right-hand splint. On 12/27/23 at 10:00 AM, R1 was observed lying in bed without a right-hand splint. On 12/27/23 at 1:18pm, V8 (Restorative Aide) was observed on the nursing unit. V8 was observed entering a resident's room at 1:19pm and exiting at 1:35pm. V8 was observed entering another resident's room at 1:35pm and exiting room at 1:55pm. V8 was then observed walking down hallway towards empty resident rooms. V8 was not observed providing PROM (Passive Range of Motion) therapy with R1. V8's documentation in R1's electronic medical record, dated 12/27/23 at 2:30 PM, notes V8 completed 15 minutes of PROM and applied right hand splint for 15 minutes. On 12/27/23 from 2:05pm until 2:46pm, R1 was observed for wound care treatment. R1 was not wearing a right-hand splint. V8 was not observed at any time entering R1's room and providing therapy for R1. R1's functional abilities assessment, dated 10/27/23, notes R1 with impairment in range of motion in both upper extremities (shoulder, elbow, wrist, hand). On 12/28/23 at 8:50am, V7 (Restorative Nurse) stated that she started working at this facility in September 2023. V7 stated that residents that are not receiving skilled therapy will receive restorative therapy. V7 stated that R1 is in restorative's PROM program. V7 reviewed R1's last two restorative assessments, dated 8/25/22 and 11/21/22. V7 stated that neither assessment notes R1 using adaptive equipment for right hand. V7 stated that restorative assessments are completed quarterly for residents. There are no further restorative assessments found in R1's medical record. On 12/28/23 at 9:40am, V9 (Rehabilitation Director) reviewed R1's OT (Occupational Therapy) evaluation dated 4/7/23. V9 stated that the therapist recommended PROM program for R1 and a resting hand splint for prevention of contracture. V9 stated that it notes right wrist with increased tone. V9 stated that this means the therapist was able to work with right hand; this is reason right hand splint was recommended. V9 reviewed R1's OT evaluation dated 9/22/23. V9 stated that it notes R1's right wrist/hand with a lot of resistance, a lot of increased tone and tightness. V9 stated that the right-hand splint would help prevent bad contractures. V9 stated that evaluation also notes slight hand contracture of R1's right hand. V9 informed that R1's right hand splint and PROM program were not reordered after R1 returned from hospital on [DATE]. V9 stated that the splint and PROM program should have been re-ordered with each re-admission to this facility. V9 stated that R1's right hand splint ordered previously notes for R1 to wear at all times except with bathing or receiving PROM. V9 stated that PROM was ordered daily previously. R1's OT (occupational therapy) evaluation, dated 4/7/23, notes R1 was seen to assess therapy needs, splint assessment, and develop a restorative program. Musculoskeletal assessment noted impairments to both upper extremities. R1's right wrist with no active range of motion, passive range of motion within functional limits but with increased tone. R1 will benefit from a resting hand splint for right hand to decrease risk of contracture. R1 referred to restorative therapy for PROM of all extremities. R1's OT evaluation, dated 9/22/23, notes R1's right wrist with no active range of motion, passive range of motion within functional limits but with spasticity and stiffness noted. R1 with slight contracture noted in right hand. R1 will benefit from continued restorative program for PROM of both upper extremities, positioning in bed as well as additional daily application of a resting hand splint to right hand for prevention of contractures and maintaining current PROM. The therapist trained restorative staff on proper PROM/stretching technique for both upper extremities and completed x 10 repetitions for all joints on all planes. Additionally trained restorative staff on proper application of resting hand splint on right hand. R1's POS (Physician Order Sheet), dated 9/21/23, notes an order for restorative splint/brace to be on at all times to assist in contracture management/maintenance of current ROM (range of motion)/pain management. Special instructions: remove for bathing, ADLs (activities of daily living), and skin checks. This order was not re-ordered upon re-admission to this facility on 10/20/23 or 12/2/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow its Accident/Incidents Reporting policy by not completing an incident report, failing to document in the progress notes, failing to assess and monitor for any changes of condition, and failing to notify the physician and family immediately after an incident. The facility also failed to follow its Fall Prevention and Management policy by not implementing fall interventions and failing to update fall care plan after a fall for two (R1, R2) of three residents reviewed for falls. These failures caused a delay in treatment and hospitalization of R1 who sustained a left femoral neck fracture that required surgery. Findings include: 1.) On 12/5/23 at 9:52AM, observed R1 lying in bed. She is awake but confused and restless. Her blanket is by the foot part of her bed. The bed is not on the lowest position. The floor mattresses are folded on the floor. The call light is not within reach. The abductor wedge is at the bedside. Called V9 (Certified Nurse Assistant/CNA) to R1's room and showed V9 the observation. V9 said R1 finished her breakfast in bed before 9:00 AM. V9 said R1 is restless, keeps removing her abductor wedge in between her legs. V9 said that R1's floor mattress should be laid on bilateral sides of the bed and the bed should be on the lowest position. V9 CNA adjusted the bed on the lowest position. On 12/5/23 at 10:00 AM, called V10 (Registered Nurse/RN) and informed of above observation. V10 said that she observed R1 when she made rounds this morning with floor mattresses folded. V10 said that CNAs folded it to provide space and way for the other 2 residents when up in wheelchair for them to get out from the room. V10 said that the floor mattresses should be on both side of R1's bed for safety. On 12/5/23 at 10:30 AM, reviewed R1's medical record with V10. V10 said that R1 is ambulatory with unsteady gait, and she is at high risk for falls. There is no fall incident report and no documentation written in R1's progress notes for 11/2/23. Documentation indicated on 11/3/23 R1 was sent to the hospital due to left hip pain and was admitted with left femur fracture. On 12/5/23 at 12:37 PM, V12 (RN) said that she worked with R1 on 11/2/23 3-11 shift. She said that R1 has unsteady gait and limping when ambulating. She said, around 7:00 PM she went to R1's room and observed R1 bending over to pick up bandage on the floor, by the time she approached R1, she was already down on the floor. She was sitting in the middle of the 2 beds. She left R1 and called for help. When she came back to the room with other staff (V13 CNA, V14 CNA, V15 CNA, and V16 RN) with her, R1 was able to move herself by scooting in a sitting position and reached by the foot part of the bed closer to the door. They transferred her via mechanical lift to the wheelchair. R1 denied any pain. V12 said she assessed R1, and no injury was noted. She did not document the incident in the progress notes and did not complete an incident report. She did not notify R1's PCP (primary care physician) and family about the incident happened because R1 did not complain of any pain and no injuries were noted. She forgot to document the incident in the progress note but she endorsed to the next shift (V21 Agency Licensed Practical Nurse/LPN) what happened. She said, the following day when R1 complained of pain on her left hip, the PCP and family was notified. She said, she should document in the progress note of what happened, complete an incident report, and notified her DON (Director of Nursing) of the incident. On 12/5/23 at 1:03 PM, V13 (CNA) said that she worked on 11/2/23 3-11 shift. V13 said, R1 ambulates with unsteady gait due to her limping. V13 said, she was called by V12 (RN) to help R1. V13 said, she found R1 sitting on the floor by the foot part of the bed close to the door. There were 3 CNAs (V14, V15 and herself) and 2 Nurses (V12 RN and V16) who transferred R1 to wheelchair using gait belt. Four of them assisted R1 to wheelchair while V15 held the wheelchair. R1 was wheeled to the nursing station for monitoring because R1 is confused and trying to get up from wheelchair. On 12/5/23 at 1:24 PM, V14 (CNA) said that he worked on 11/2/23 3-11 shift. He said V13 (CNA) called him to help R1. He observed R1 was lying on the floor by the end of the bed, facing the window. They picked her up and assisted to the wheelchair. V15 (CNA) held the wheelchair and while the rest assisted R1 to the wheelchair. They did not use gait belt because R1 can still stand up. R1 was wheeled to the nursing station for supervision. On 12/5/23 at 1:30 PM, V7 (Restorative Nurse/Fall Coordinator) said that she is responsible for implementing fall interventions and investigation of fall incidents. The floor nurses do the fall assessment upon admission/re-admission, quarterly assessment, annually, significant change of condition and after each fall. She updates the care plan after each fall incident based on root cause analysis/fall investigation. Fall is any change on plane, could be kneeling, lying, anybody position on floor. It could be witnessed or observed. Reaching on the floor or bending over that ended body to land on the floor is considered a fall and should be documented in the progress notes and need to complete an incident report. Any unusual incident happened to the resident should be documented in the progress notes and complete an incident report. The nurse should report the incident to the DON or ADON. Then the nurse will be informed of what immediate intervention should be put in place. Root cause analysis/fall investigation is done by the IDT (Interdisciplinary team) during daily morning meeting. Then the fall care plan will be updated based on the root cause analysis/fall investigation to prevent future falls. R1 is ambulatory but with unsteady gait due to her limping. R1 is at high risk for falls and had multiple fall incidents. On 12/5/23 at 2:22 PM, V15 (CNA) said that she has been working in the facility for 6 weeks. The first time she worked by herself was on 11/2/23 3-11 shift when she took care of R1. She said she was called to R1's room and observed R1 sitting on the floor by the foot of her bed with her both legs extended. She did not know what happened. She held the wheelchair as the 2 nurses and 1 CNA assisted R1 to the wheelchair. R1 was wheeled to the nursing station. V15 said she placed R1 to bed around 9:00 PM by herself. R1 has having hard time pivoting/turning. R1 moaned but when she asked R1 if she is in pain, R1 denied it. V15 reported to V12 (RN) of her observation. V15 said, V12 only endorsed to her that R1 needs 1 person assist and is incontinent. V12 did not inform her that R1 needs supervision, and she is at risk for fall. V15 said that after dinner, R1 was sitting by the nursing station. She does not know who wheeled R1 to her room or if she wheeled herself or walked to her room. On 12/6/23 at 10:13 AM, V21 (Agency LPN) said that she worked on 11/2/23 at 11-7 shift and received endorsement from V12 (RN) that R1 had fall incident and denied any pain. V21 said that she did not know the details of R1's fall. V21 said that she monitored R1, but she can't remember documenting it. V21 endorsed to the next shift and reported to V22 (LPN) that R1 fell on [DATE] 3-11 shift. V21 endorsed to V22 to call R2's PCP (Primary care physician). V21 said that she was still in the facility when R1 was sent out to the hospital for evaluation. V21 said that she does not know why V12 did not complete an incident report for R1 and did not document it in the R1's progress notes of what happened. V21 said that assessment, documentation, and reporting to PCP and family should be done immediately after the incident occurred. On 12/6/23 at 10:20 AM, Review R1's medical records with V7 (Fall Coordinator). R1's fall incident that occurred on 11/2/23 was not documented in progress notes. Fall incident report was not done. R1's PCP and family were not immediately notified after the incident. R1 was not monitored for any changes of condition after the incident. Informed V7 that R1's fall prevention interventions were not implemented. R1 was observed on 12/5/23 that she is not up in chair before breakfast. The bilateral floor mattresses were folded while she was in bed. Her bed was not in the lowest position. On incident of 11/2/23, R1 was not in high traffic area so staff can monitor her. She was observed bending over to pick up something on the floor and by the she approached her she was already sitting down on the floor in her room. R1 was transferred to from wheelchair to bed by V15 (CNA) by herself instead of 2 persons assist. Informed V7 that R1's fall care plan was not updated after she came back from the hospital on [DATE] with diagnosis of total left hip arthroplasty due to fracture hip. On 12/6/23 at 11:52AM, V18 (CNA) said that he took care of R1 on 11/2/23 11-7 shift. V18 said that R1 slept during the entire shift, he did not change or repositioned her until 6:30 AM when he was about to provide incontinent care and get her up. R1 complained of pain, and he observed redness on her left hip. V18 kept R1 in bed and reported to the incoming CNA V9. V18 said that he did not report to V21 (Agency LPN) because she was busy, and it was about time for him to leave. V18 said that V21 did not inform him that R1 fell on 3-11 shift. V18 said, V17 (CNA) told him that R1 fell on 3-11 shift. V18 said that he is aware that he should report his observation regarding R1's complaint of pain to V21. On 12/6/23 at 12:50 PM, V1 (Administrator) said that V12 (RN) should complete an incident report and document the incident report in R1's progress notes immediately after the incident. The nurse should follow and implement their policy. On 12/6/23 at 1:40 PM, V17 (CNA) said that he worked on 11/2/23 11-7 with V18 (CNA). V17 said that he heard from the 3-11 CNAs that R1 fell and was found sitting on the floor in her room. All of them assisted R1 from floor to her wheelchair. V17 said that he assisted V18 to provide care to R1 because she was complaining of pain on her left hip. R1 was moaning and saying polish language Boli which means pain. They provided incontinence care to R1 at 12:00 AM and 3:00 AM, repositioned at 6:00 AM. They reported R1's complaint of pain to V21 (Agency LPN) each time they provided care. On 12/6/23 at 1:49 PM, V16 (LPN) said that she worked with V12 (RN) on 11/2/23 3-11 shift. V12 called her for help to R1's room. She observed R1 sitting on the floor by the foot part of her bed. All staff (V12 RN, V13 CNA, V14 CNA, V15 CNA, and herself) assisted R1 to her wheelchair. R1 was wheeled to the nursing station. R1 is confused and always attempted to get up and walk. R1 ate in the dining room for dinner. R1 can get up and walk from her wheelchair. V16 said that she is not aware that V12 did not complete an incident report for R1 and did not document in her progress notes of what had happened. V16 said that if she is the nurse assigned for R1 she will complete the fall incident report, document in progress notes what happened including her assessment, notify physician and family member and monitor resident for any changes of condition. On 12/6/23 at 2:15 PM, V2 (Director of Nursing/DON) said that she reviews the fall incident with IDT. Incident report is completed in any unusual occurrence with resident that cause or may potentially cause an injury. Informed V2 of interviews done with all staff who worked with R1 on 11/2/23, 3-11 shift and 11-7 shift. Informed V2 of CNAs reported R1 's complaint of pain on her left hip to the nurses on both 3-11 and 11-7 shift but was not addressed. Reviewed R1's MAR (Medication Administration Record) for 11/2/23 and 11/3/23, no nurses administered with as needed pain medication. V2 presented R1's comprehensive pain assessment done by V12 (RN) as late entry after R1 was admitted to the hospital due to fracture left hip. V2 said that V12 did not complete an incident report nor document it in the progress note because V12 said that R1 intentionally sat down on the floor but if V12 is changing her statement then she should complete an incident report because it's considered as a fall incident. V2 said that she recognized the incident as a fall and did fall in-services on 11/10/23. Informed V2 that after R1 was re-admitted on [DATE] from hospital with left total hip arthroplasty due to fracture left hip, R1's fall care plan was not updated and she had multiple fall incidents on 11/10/23, 11/11/23 and 11/19/23. R1 is initially admitted on [DATE] and re-admitted on [DATE] with diagnosis listed in part but not limited to Displaced fracture of base of neck of left femur subsequent encounter for closed fracture with routine healing, Presence of left artificial hip joint left total hip arthroplasty, Unilateral primary osteoarthritis left hip, Disorders of bone density and structure Osteopenia, Abnormalities of gait and mobility, Generalized anxiety disorder, Low back pain, Cognitive communication deficit, osteoarthritis, idiopathic scoliosis. admission fall assessment done on 9/29/23 indicated she is at high risk for fall. re-admission fall assessment done on 11/9/23 indicated she is at high risk for fall. Care plan indicates that she is at risk for falling related to muscle weakness, history of falls, oblivious to safety, unsteady gait and is not compliant with using assistive device or allowing staff assistance when attempting to ambulate. Interventions: Up in chair before breakfast per resident preference. Bilateral floor mats. Keep resident in high traffic area so staff can monitor. Resident will be monitored often while in bed. 2 persons assist with transfer. Keep the bed in the lowest position with brakes locked. She is at risk for ADL (Activity of Daily living) decline related to muscle weakness and cognitive impairment. Interventions: Locomotion and Walking requires supervision. She is unable to make her needs know due to impaired cognition, poor insight with judgement, poor safety awareness as evident by attempting to ambulate without assistance and irritability when redirected. Interventions: Observed and report changes in resident's condition. Observed for non-verbal signs of distress (e.g., guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal). Turn reposition, communicate, provide peri care, assess for pain, provide liquids/food as needed. MDS (Minimum Data Set) quarterly assessment on 11/1/23 Section GG Functional abilities and goals. Coded: Moderate assistance for Walking; Maximum assistance for transfer. R1's fall incident reports for 2023: 1). 11/19/23 Unwitnessed fall. R1 was found sitting on the floor in her room by CNA. 2). 11/11/23 Unwitnessed fall. R1 was seen sitting on the floor in her room [ROOM NUMBER]). 11/10/23 Unwitnessed fall. R1 was found sitting on the floor mattress in her room. 4) 10/27/23 Unwitnessed fall. R1 was found sitting on the floor in her room. 5) 10/5/23 Unwitnessed fall. R1 was observed scooting from her room into the hallway in a sitting position. 6) 4/14/23 Unwitnessed fall. R1 was noted sitting on the floor by the nurses' station. 7) 4/4/23 Unwitnessed fall. R1 was found lying in prone position having nasal bleeding in the dining room. 8) 3/19/23 Unwitnessed fall. R1 was noticed laying on the floor in the hallway next to the entrance of her room. 9) 1/24/23 Unwitnessed fall. R2 was found on the floor on her right side in the hallway. No fall incident report or any incident report done on 11/2/23 in R1 medical records. R1 initial report of facility reported incident dated 11/3/23 indicated: On 11/3/23 R1 with complaint of left hip pain during initiation of morning care. CNA immediately notified nurse on duty. R1 provided with ordered pain medication and nursing assessment completed. The provider was contacted with order to transfer to hospital for evaluation and treatment. R1 is ambulatory and uses a wheelchair when tired. Based on initial investigation, R1 was observed in her room the previous evening bending over to reach an item on the floor and sat herself down on the floor in the process. R1 has no complaints of pain. Facility received report from the hospital that R1 has fracture of the left femoral neck and mild superior distal displacement of the distal fracture fragment is seen. Summary of the investigation: R1 has history of osteopenia and osteoarthritis, along with the behaviors of resisting care, being aggressive and scooting on the floor. On 11/2/23 around 8:00 PM, R1 was noted by V12 (RN) to be crouched down to pick an item on the floor and that she sat on the floor left hip first. R1 was unable to get herself up from her sitting position on the floor. While V12 looked for assistance R1 was able to scoot herself towards the doorway. Several staff assisted her up from the floor into the wheelchair. R1 was refusing care at this time. Staff brought her out of her room and on several occasions R1 stood up from her wheelchair while at the nurses' station. Later that evening she was assisted in transferring herself to bed. In the early morning of 11/3/23 R1 was noted to be in pain and her left leg was slight shortened. The nurse on duty administered pain medication and notified physician of change of condition and received orders to transfer to hospital. Conclusion: R1's co morbidities such as age, severe degenerative joint disease, osteoarthritis and osteopenia and the action of crouching herself and sitting position on the floor likely contributed to the non-displaced oblique fracture of the left femur. R1's hospital record on 11/3/23 indicated: Chief complaint: patient presents with fall. History of present illness: Patient was noted to have left discomfort today while turning, some abrasions on the left hip. She is ambulatory without assistance at baseline, so unwitnessed fall was suspected. Patient unable to recall events and she is very poor historian. Imaging study showed left femoral neck fracture. Mild superior displacement of the distal fracture fragment. She was given fentanyl for pain. Orthro consulted. Assessment and Plan: Left hip fracture to presumed fall. Ortho consult pending, most likely surgical repair. Pain control. 2.) On 12/6/23 at 9:30 AM, observed R2 sitting in the dining room with V7 (Fall Coordinator). Observed R2 sliding from her wheelchair with wheelchair cushion. V7 said that R2 has fall prevention intervention of anti-slip material placed on her wheelchair seat. V7 called V19 (CNA) for assistance. V7 and V19 assisted R2 to stand and observed no anti-slip material was applied to R2's wheelchair seat. Observed R2's wheelchair cushion slide half of it from the wheelchair seat. V7 said that R2 should have anti-slip material on her wheelchair seat to prevent it from sliding from her wheelchair. V7 and V19 corrected the position of R2's wheelchair cushion. On 12/6/23 at 9:40 AM, V9 (CNA) said that she is the CNA assigned for R2 and got her up in wheelchair. She said, R2 should have anti-slip material to her wheelchair seat, but she cannot find it. On 12/6/23 at 11:25 AM, Review R2's medical records with V7 (Fall Coordinator). Informed V7 that R2's fall care plan was not updated after fall incident on 12/1/23. R2's fall prevention intervention of anti-slip material to her wheelchair seat was not implemented. R2 was observed with V7 on 12/6/23 in the dining room sliding from wheelchair because she did not have anti-slip material in her wheelchair seat. R2 is admitted on [DATE] with diagnosis listed in part but not limited to Dementia with behavioral disturbance, Osteoarthritis, Age related osteoporosis, anxiety disorder. Fall admission assessment on 8/2/23 indicated she is at high risk for fall. Recent fall assessment after fall incident on 12/1/23 indicated that she is at high risk for fall. Care plan indicates that she is at risk for fall related to impaired judgement, confusion, history of falling, muscle weakness, dementia, anxiety, dermatitis, back pain hypertension, gastroesophageal reflux, glaucoma, and vertigo. Intervention: Place anti-slip material in wheelchair. Fall care plan was not updated after she has fall incident on 12/1/23. R2 fall incident reports: 1) 12/1/23 Unwitnessed fall. R2 was found sitting on the floor next to her bed. 2) 11/24/23 Unwitnessed fall. R2 was found sitting on the floor by her bed. 3) 9/27/23 at 9:30 AM Unwitnessed fall. R2 fell in the dining room. 4) 9/27/23 at 1:20 PM Unwitnessed fall. R2 fell in the dining room. 5) 9/24/23 Unwitnessed fall. R2 found lying on her right side. 6) 9/16/23 Unwitnessed fall. R2 was found sitting on the floor next to her bed. 7) 8/29/23 Unwitnessed fall. R2 was found sitting next to her wheelchair. Fall care plan was not updated after she has fall incident on 12/1/23. Facility's policy on Accident and incident report 4/2019 indicates: Objectives: to document all accidents/incidents occurring to residents, visitors, and employees. Procedure: 1. Resident: a. Provide any necessary emergency care. b. Notify the nurse, who then must notify Physician and family. c. Follow up to be continued at minimum for 72 hours which should vital signs, ROM (Range of motion), skin abnormalities, responsiveness general condition changes observed in injury site, etc. d. A complete, thorough, and accurate incident report will be completed as well as a general summary of the event within the resident's progress notes of actual or suspected injuries, family and physician notification and interventions implemented at time of incident. 4. In all cases: a. There must be an exact description of the accident/incident: 1. Location 2. Time and date 3. Level of consciousness 4. Description of injury 5. Description of any emergency care given 6. Vital signs for residents 7. Any persons notified of the incident. Facility's policy on Fall prevention and management 2/2023 indicates: Purpose: to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best way we currently know of preventing falls. The falls prevention and management program are designed to assist staff in providing individualized, person centered. The falls prevention and management program provide a framework and tools to identify and communicate about a resident's risk of fall. Additionally, the program addresses a safe process to follow for supporting a resident who has experienced a fall event. Fall prevention Practices: 1. Universal fall precautions 2. Standardized assessment of fall risk factors 3. Care planning and interventions to address risk factors 4. Post fall response including analysis of procedures and outcomes Universal Fall Precaution: are safe measures that are taken to reduce the chance of falls for all residents, regardless of individual fall risks. Care planning and interventions to address fall risk factors: * The care plan addresses universal fall precautions and individual fall risk factors as applies to the resident. *A fall risk care plan will be implemented as part of the baseline care plan to address universal fall precautions and as part of the comprehensive care plan utilizing information from the fall risk assessment. The care plan will be reviewed and revised at least quarterly and with any fall event the resident might experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the fall prevention policy to develop, implement, reevaluate the effectiveness of interventions to prevent or reduce the risk of falling for a resident with dementia, poor safety awareness, and high risk for falls. This failure affected one of three residents (R1) reviewed for fall prevention intervention. These failures resulted in R1 being involved in a fall incident causing pain to the left hip area. R1 was sent to the local hospital and evaluated and treated for a displaced left femur fracture. Findings include: R1's face sheet shows diagnosis of Parkinson's disease, Alzheimer's with late onset, tremors, abnormalities of gait and mobility, dementia. MDS dated 7.21.23 section C denotes BIMS score of 7(cognitively impaired). Section G for bed mobility denotes R1 is extensive assist with one-person physical assist, transfer denotes R1 is extensive assist with one-person physical assist. Balance during transition and walking for surface-to-surface shows 2- not steady only able to stabilize with staff assistance. Facility final investigation to the department dated 8.14.23 denotes in-part date of occurrence 8.12.23, R1 is the resident, occurrence description: R1 was found on the floor next to his bed. Bed was in lowest position R1 was unable to state what happened. R1 complaint of discomfort to the left leg on exam. Nurse on duty called medical doctor and receive orders for X-rays. While waiting for X-rays it was noted to have swelling to the left hand and fingers. Nurse on duty call medical doctor for further orders, at this time receive orders to send to Emergency department for further evaluation. Nursing on duty for follow up and was informed by hospital that R1 was being admitted with sepsis. On 8.13.2023 at approximately 9:00 PM nurse on duty also have follow up with V1 who informed nurse on duty that R1 had a hip fracture. On 8.14.2023 the nurse at the hospital who stated R1 was admitted with left intertrochanteric fracture was also admitted with sepsis full investigation to follow. Final report denotes in-part, R1 is a [AGE] year-old long term care resident. R1 have (sic) a history of Alzheimer's, Parkinson's osteoarthritis, anxiety depressive disorder and lumbar fracture R1 has a BIMS of 7 and is extensive assist for activity living. R1 has behavioral of whistling, shanking half rails when in his room. R1 also has a behavior getting up out of bed without assistance. Interview with V2 (Certified Nurse Assistant/CNA) on 8.12.23 I was assigned to R1, I made rounds on him around 730am. V2 states she set him (R1) up for breakfast around 8:30 am, and he ate 75%. V2 states at 10:00am R1 was observed on his back at the head of other bed in room. V2 states he (R1) awake and alert to his norm. V2 states that she then went and informed NOD (Nurse on duty) that R1 fell. They went back to his room were NOD assessed him (R1) and took vital signs. V1 states he denied pain at this time. V2 stated that about 15-20 minutes later he (R1) c/o (complained of) left leg pain. Interview with V3 on 8.12.2023 I (V3) was assigned to R1 around 10:00 AM V2 on duty informed me that R1 was on the floor in the room. When I arrived to the room R1 was on the floor next to other bed and almost sitting position. R1 was alert to his norm. Assessed him and at this time he complained of no pain or discomfort. Neuro checks done at this time and were WNL (within normal limits). R1 was assisted up and back to bed no injuries noted at this time. V3 states about 15 minutes later aide on duty inform him of pain to left hip. On assessment I noted no deformities to area MD (medical doctor) called and nurse on duty spoke with V8 (Nurse Practitioner). V8 gave orders for X-rays and labs at this time X-ray and lab notified of orders. Interview with V9 (CNA) on duty 8.12.23 was assigned to R1 from 11pm to 7:00am, states that R1 was alert to his norm during the night. That he whistled for assistance during the night, states that R1 got up during the night and was easily directed back to his bed. Interview with V10 (nurse) on 8.12.23 I was nurse assigned to R1 from 11pm to 7:00 am. I received R1 asleep during my initial rounds. V10 states that R1 was alert to his norm. R1 had gotten out of bed 2-3 times during the night and was easily directed back to bed. Conclusion denotes in-part investigation included record review and interviews. The investigation reveals that R1 frequently gets up on his own and ambulates a few steps with an unsteady gait. On August 12, 2023, R1 experienced a fall while self-ambulating in the room. He was unable to express to staff what happened to cause the fall. On 9.6.23 at 11:26am V2 (CNA) said she was assigned to work with R1 on 8/12/23 7-3:00pm shift. V2 said she assisted R1 with breakfast that morning. R1 was in the bed. V2 said she was in the room caring for another resident when the housekeeper informed her that R1 fell. V2 said when she arrived to R1's room, R1's roommate was trying to assist R1 up from the floor. V2 said she intervened. V2 said R1 was laying on the floor on his back, his head was near the roommate's bed. V2 said she went and got the nurse. The nurse arrived. R1 denied pain. The nurse assessed R1. V2 said R1 was picked up, placed back in the bed manually using a gait belt. V2 said about 15 minutes later when she was going to get R1 dressed, R1 complained of pain to the left hip. V2 said she informed V3 (Nurse) of R1 complaint of pain. V2 said she don't know if V3 gave R1 anything for pain. V2 said during her shift she informed V3 about 3 times of R1's complaints of pain. V2 said one time she informed V3, V3 said that he has to follow the doctors' orders, and the doctor an X-ray. V2 said she worked a double (3pm-11pm shift). V2 said R1 had complaints of pain during the evening shift also. V2 said she think she informed the evening nurse about 3-4 times of R1 complaint of pain. V2 said R1's daughter did visit R1 on 8.12.23. V2 said R1 did not say how he fell. R1 did not say what he was doing when he fell. V2 said R1 has dementia. V2 said R1 bed was in a low position. R1 did not have on any shoes. R1 did not have on any skid free socks. V2 said she don't recall were R1's call light was at. V2 said R1 was a fall risk. V2 said R1's gait was not steady. V2 said R1 could transfer from bed to chair with assistant from staff. On 9.6.23 at 1:07pm V3 (Nurse) said he was assigned to R1 on 8.12.23. V3 said it was around 10:30am when V2 informed him that R1 had fallen. V3 said when he came in the room to assess R1, R1 was on the floor, kind of near the roommate's bed in sitting position almost. V3 said when he asked R1 how he fell, R1 just shrugged his shoulders, R1 did not say anything. V3 said he figured R1 was going to look at the roommate's shoes. V3 said because R1 was near the roommate's bed he figured R1 was going to look at the roommate's shoes. V3 said R1 did not tell him that he was going to look at the roommates' shoes. V3 said he was not aware that R1 was a fall risk. V3 said he found out on the day of the fall that R1 was a fall risk. V3 said he does not know what fall precautions R1 had in place. V3 said the social worker knows what fall precautions R1 has in place. V3 said the social worker puts the fall precautions in place. V3 said when he was completing the fall assessment for R1, that when he noticed R1 had a fall before and that R1 was a fall risk. On 9.7.23 at 12:32pm V9 (CNA) said he did not tell the facility that R1 got up during the night shift. V9 said R1 shakes the bed rails and whistle when he wants a brief change. V9 said he did speak to the DON (Director of Nursing) or administrator regarding this, but he did not say R1 got up that night on 8.12.23. On 9.7.23 at 12:59pm V10 (Nurse) said he did not tell the facility that R1 got up during the night shift. V10 said he heard R1 whistle that night on two occasions. V10 said when R1 whistles he wants a brief change. V10 said maybe V9 told him that R1 got up, V10 then said it was weeks ago, he doesn't remember. V10 said the previous nurse did report to him that R1 had a fall that morning, and the doctor ordered an X-ray. On 9.7.23 V6 (Care plan/ Minimum Data Set Coordinator) said she updates the care plan for medical diagnosis and post fall interventions. V6 said she developed R1's fall risk care plan. V6 said R1 is at risk for fall due to muscle weakness, unsteady gait, Parkinson's, tremors, anxiety, and history of falls. V6 said the team discuss the fall and develop fall interventions together. V6 said the fall interventions would be based on the root cause of the fall. V6 said she do not determine the root cause of the fall. R1 fall investigation conclusion reviewed with V6. V6 said the conclusion is that R1 frequently gets up on his own and ambulates a few steps with an unsteady gait. V6 said R1 getting up with an unsteady gait, with his diagnosis of dementia makes him at risk for falls. V6 said she don't know if the staff reported to her that R1 gets up frequently. V6 said she should have been made aware of R1 getting up frequently. V6 said she can't say what fall interventions would have been put in place because this is discussed with a team. V6 said an immediate intervention post R1 fall on 8.12.23 was to complete an Xray. R1 fall interventions reviewed with V6 which denotes placing R1 near to the nurse station when out of bed for supervision. V6 said this is so that staff can monitoring R1 because R1 will tray and self-transfer when sitting in his room at the bed side. Instruct resident in the proper use of any appliance or devices to aide in balance. V6 said R1 used a wheelchair, and staff is to ensure R1 is not leaning when sitting in the wheelchair. Instruct the resident to ask for assistance prior to attempting to transfer or walk. V6 said R1 should ask for assistance before trying to transfer or walk. V6 was asked if R1 had dementia and would he remember to ask for assistance. V6 was asked if R1 asked for assistance before getting up from bed on 8.12.23. V6 said she miss wrote that intervention, it should have read that staff should remind R1 to ask for assistance before trying to transfer or walk. V6 was asked if R1 would be able to remember to ask for assistance before getting up to transfer or walk. V6 then said maybe the facility could have put a sign up to tell R1 to use the call light before transferring or walking. V6 was asked if R1 would remember to read the sign before transferring or trying to get up. V6 was asked if the interventions be effective if R1 has dementia and may not be able to remember to ask for help before trying to transfer or walk. V6 said the interventions might not be effective. R1 fall risk assessment reviewed with V6 dated 6.28.23, denotes fall score of 2 (low risk). V6 said the fall risk assessment is not correct, it does not capture all the risk factors for R1. If the assessment was completed correctly the score would be 10 thereby placing R1 a risk for falls. V6 said balance problem while standing should have been checked (score1), confined to chair totally unable to ambulate without assist (score 3), and contributing factors (score 2) medications taken (score 2). R1's emergency room record dated 8.13.23 denotes in part emergency room by ambulance from skilled nursing facility. Patient had a fall yesterday evening was really scheduled for an inhouse X-ray and assessment by physician there but apparently this never happened. Today the patient is less responsive than baseline and has acute pain over the left hip patient only able to respond to his name otherwise nonverbal during assessment. This is a [AGE] year-old male with past medical history of vascular dementia Lewy body dementia, Parkinson's disease, chronic bronchitis presenting to ED (emergency department) for hip pain phone and concerns for sepsis. Patient presenting on stretcher with left leg folded and crossed under self, painful to straighten patient shouting and grimacing when placed in anatomic position was shortened and externally rotated severe tenderness on the lateral compression of hip. ED diagnosis sepsis close displaced intertrochanteric fracture on left femur. R1 care plan for fall with problem start date 4/20/2023 denotes in-part one is a risk for falls related to muscle weakness unsteady gait diagnosis of Parkinson's tremors anxiety and history of falling. Goal-R1 will remain free from major fall related injury. X-ray per order. Place resident near the nurse's station when out of bed for supervision and monitoring and guidance. Instruct resident in the proper use of any appliances or devices to aid in balance. Instruct resident to ask for assistance prior to attempting to transfer or walk. Keep it in lowest position with brakes locked. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Observed frequently and place in supervised area when out of bed. Occupy resident with meaningful distractions. Orientate resident when there have been new furniture placement or other changes in environment. Provide one or more staff assist if resident has mood/ behavior, impaired mobility/ weakness pain or discomfort, restlessness and or agitation, provide well maintained footwear. Facility policy titled Falls prevention and management dated 3/2022 denotes in part the purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best ways we can currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualized person centered care. The falls prevention and management program provide a framework and tools to identify and communicate about a resident risk of falls. Additionally, the program addresses a safe process to follow supporting a resident who has experienced a fall event. Universal fall precautions- universal fall precautions are safety measures that are taken to reduce the chance of falls fall residents regardless of individual fall risk. Care planning and interventions to address fall risk factors- development of fall risk care plan is based on results of falls of assessment as well as investigation of all circumstances and related resident outcomes. The care plan addresses universal fall for cautions and universal fall risk as applies to the resident. A fall care plan will be implemented as part of the baseline care plan to address universal phone caution and it's part of the comprehensive care plan utilizing information from the fall risk assessment the care plan will be reviewed and revised at least quarterly and will any fall event the resident might experience. Post fall response-past history of a fall is the single best predictor of future falls. In fact, there's 30-40% of those residents who fall will so do it again. Thus, it is critical for staff to respond quickly and effectively after a fall. A post fall response includes immediate actions to ensure the safety of the resident assessment clinical review investigation and observations of the dictation of immediate action to prevent further falls notification of appropriate parties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pain management after a fall for a dementia resident observed by the resident's family to have facial grimacing and acting out of character and complaining to staff of left hip pain during dressing. This affected one of three residents (R1) reviewed for pain management. This failure resulted in the staff being notified that R1 was in pain by a family member post fall and R1 not receiving any pain medication. R1 was transferred to the local hospital where R1 was diagnosed and treated with a displaced left femur fracture. Findings include: On 9.6.23 at 11:26am V2 (CNA) said she was assigned to work with R1 on 8/12/23 7-3:00pm shift. V2 said she assisted R1 with breakfast that morning, R1 was in the bed. V2 said she was in the room caring for another resident when the housekeeper informed her that R1 fell. V2 said when she arrived to R1's room and R1's roommate was trying to assist R1 up from the floor. V2 said she intervened, V2 said R1 was laying on the floor on his back, his head was near the roommate's bed. V2 said she went and got the nurse, the nurse arrived, R1 denied pain, the nurse assessed R1. V2 said R1 was picked up, placed back in the bed manually using a gait belt. V2 said about 15 minutes later when she was going to get R1 dressed, R1 complained of pain to the left hip. V2 said she informed V3 (Nurse) of R1's complaint of pain. V2 said she don't know if V3 gave R1 anything for pain. V2 said during her shift she informed V3 about 3 times of R1's complaints of pain. V2 said one time she informed V3, V3 said that he has to follow the doctors' orders, and the doctor an X-ray. V2 said she worked a double (3pm-11pm shift). V2 said R1 had complaints of pain during the evening shift also. V2 said she think she informed the evening nurse about 3-4 times of R1's complaint of pain. V2 said R1's daughter did visit R1 on 8.12.23. On 9.6.23 at 10:50am V1 (R1's family) said she was informed that R1 had a fall. She visited R1 around 6:00pm on 8.12.23 and notice R1 was in pain. R1 was acting out. R1 was not being himself and R1's eyes were rolling up. V1 said she told the nurse that R1 was in pain. V1 then said she don't know if it was the nurse or CNA that she informed of R1 pain. V1 said she don't remember if R1 got something for pain. On 9.6.23 at 1:07pm V3 (Nurse) said he was assigned to R1 on 8.12.23. V3 said it was around 10:30am when V2 informed him that R1 had fallen. V3 (Nurse) said 15-20 minutes after picking R1 up after the fall V2 informed him that R1 was experiencing pain. V3 said when he assessed R1 for pain, R1 denied pain. V3 said he did not give R1 anything for pain. V3 said R1 has dementia. V3 was asked would it be reasonable to believe due to R1's dementia he may not be able to verbalize his pain during your assessment. V3 said that makes since. Review of R1's medication administration record dated 8.12.23, there is no documentation denoting that R1 received pain medication for the complaint of pain in the hip on 8.12.23. On 9.7.23 at 9:44am V11 (Director of Nursing) said she V3 should have given R1 something for pain. R1's pain assessment dated 8.12.23 at 12:23pm denotes in-part, indicators of pain- vocal complaints of pain (that hurts, ouch, stop). Received scheduled pain medication regimen NO is checked. R1's physician order sheet with start date of 4.13.23 shows orders for acetaminophen tablet 500 mg (milligrams) one tablet orally every 8 hours PRN (as needed). Naproxen tablet 500 mg (milligrams) one tablet oral twice a day PRN (as needed). R1's nurse's note dated 8.13.23 1:31pm states Writer spoke with (Nurse Practitioner) about resident. Writer received orders to send patient out to (local hospital emergency room) for follow-up. Orders received and carried out. R1's emergency room record dated 8.13.23 denotes in part emergency room by ambulance from skilled nursing facility. Patient had a fall yesterday evening was really scheduled for an inhouse X-ray and assessment by physician there but apparently this never happened. Today the patient is less responsive than baseline and has acute pain over the left hip patient only able to respond to his name otherwise nonverbal during assessment. This is a [AGE] year-old male with past medical history of vascular dementia Lewy body dementia, Parkinson's disease, chronic bronchitis presenting to ED (emergency department) for hip pain phone and concerns for sepsis. Patient presenting on stretcher with left leg folded and crossed under self, painful to straighten patient shouting and grimacing when placed in anatomic position was shortened and externally rotated severe tenderness on the lateral compression of hip. ED diagnosis sepsis and close displaced intertrochanteric fracture on left femur. R1's plan of care for pain denotes alteration on comfort secondary to pain related to osteoarthritis and intervertebral disc disorders thoracolumbar region. Goal R1 will express relief/decrease discomfort as evidence by verbalization of decrease or absence of pain, relaxed facial expression and body position. Interventions are to administrator medication as per order and observe for result. Facility policy titled Pain dated 11/22 denotes in-part it is the policy of this facility to school (sic) all residents for pain identify those who are experiencing pain and assess and develop effective individualized pain management care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their abuse policy by failing to prevent an incident of staff to resident physical abuse. This affected 1 of 3 residents (R3) reviewed for abuse. This failure resulted in R3 being aggressively pushed in back into her wheelchair. R3 was subsequently sent to the local hospital and was assessed to have sustained a strained neck muscle. Findings Include: R3 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia, with other behavioral disturbances, generalized anxiety disorder, scoliosis, fusion of spine, spinal stenosis, osteoporosis without current pathological fracture and history of falling. R3's Minimum Data Set, dated [DATE] documents a brief interview for mental status score 03/15 which indicates severely impaired cognition. R3's care plan dated 8/16/22 document R3 has a diagnosis of dementia with behavioral disturbances. Interventions: allow adequate time for resident to respond; maintain a calm environment and approach to the resident; provide reassurance as needed to help the resident safe and secure. R3's screening for abuse dated 2/21/23 documents under risk measure for the likelihood of previous/recent mistreatment and potential future problems/symptoms related to mistreatment: a score of 1 which indicate low On 2/21/23 at 3:01pm, V18 (Certified Nurse Assistance/CNA) said, R3 was sitting behind the nursing station. R3 kept trying to stand up. V19 (Nurse) grabbed R3's wheelchair and slam it forcibly hard against the wall. On 2/22/23 at 5:19pm, V25 (R3's POA) said, I watch the video with R3 and V19. V19 was seen pushing R3 down forcibly in the wheelchair by her shoulder after R3 attempted to stand-up form the wheelchair. V19 look so angry on the video. I requested for R3 to go to hospital on 2/18/22. R3 was frightened. R3 looked out of sorts and upset. I was upset about the incident. Local police department report dated 2/17/23 at 16:47 documents under nature of complaint: battery. Under narrative: The following is a general summary of my recollection of events and all conversations are not verbatim. In summary dispatched to facility for a complaint of elder abuse. V18 (CNA) contacted via phone and reported that V19 (Nurse) became increasing irritated with R3 and at one point pushed R3's wheelchair causing R3 to crash into the wall. Video footage was reviewed on 2/18/23 with observations of R3 attempting to stand up multiple times. The third time R3 attempted to stand up, V19 (Nurse) can be seen entering the room visibly upset. V19 aggressively shoves R3 into the wheelchair using his right hand. V19 (Nurse) then wheels R3 into the hallway where V19 can be observed yelling in R3's face while pointing in her face with his finger. V19 makes a second lunging motion towards her, however due to the lack of camera angles, its undetermined if the lunge was an additional shove. R3's hospital record dated 2/18/23 documents: R3's family was notified yesterday that patient (R3) was forcibly pushed down by staff member at the nursing home on Thursday. He reports R3 had been complaining of neck pain which prompted visit today. Currently R3 denies any neck pain. Although R3 was denying pain initially, later did complain of some low back pain. Was offered Tylenol but declined. Hospital diagnosis: strain of neck muscle. Under neck sprain or strain documents: A sudden force that causes turning or bending at the neck can cause sprain or strain. Facility abuse final report dated 2/23/23 documents under investigation documents: On Saturday police officer returned to view footage. Officers watched the alleged interaction where the restraint was being applied by the nurse. The officer asked to see additional footage from earlier during the day before restraint was applied. At that time, V1 saw on the tape that V19 (Nurse) appeared to use force to her (R3) right shoulder to get R3 to sit back on her wheelchair after she (R3) was repeatedly trying to stand. The investigation also revealed that V19 did not follow the restraint policy and applied a plastic bag. During the course of the investigation, it was also discovered that V19 used force to encourage R3, who was a fall risk to remain in her wheelchair. While the facility believes that V19 actions were intended to protect the resident (R3) from a fall, the application of force violates facility policy and standards. V19 will be terminated. Abuse policy revised 10/2022 documents: The facility affirms the right of our residents to be free from abuse. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental mean. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accident means and that requires medical attention. Physical abuse includes hitting. Slapping, pinching, kicking, and controlling behavior through corporal punishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy on physically restraints. This affected 1 of 3 residents (R3) reviewed for restraints. This failure resulted in R3 being physically tied to a wheelchair with plastic garbage bags, restricting R3 right to move freely. Using the reasonable person theory R3 would have been embarrassed and humiliated by be tied to a wheelchair with plastic bags. Findings Include: R3 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia, with other behavioral disturbances, generalized anxiety disorder, scoliosis, fusion of spine, spinal stenosis, osteoporosis without current pathological fracture and history of falling. R3's Minimum Data Set, dated [DATE] documents a brief interview for mental status score 03/15 which indicates severely impaired cognition. R3's care plan dated 8/16/22 document R3 has a diagnosis of dementia with behavioral disturbances. Interventions: allow adequate time for resident to respond; maintain a calm environment and approach to the resident; provide reassurance as needed to help the resident safe and secure. R3's screening for abuse dated 2/21/23 documents under risk measure for the likelihood of previous/recent mistreatment and potential future problems/symptoms related to mistreatment: a score of 1 which indicate low. On 2/21/23 at 3:01pm, V18 (Certified Nurse Assistant) said, R3 was sitting behind the nursing station. R3 kept trying to stand up. V19 (Nurse) tied two clear plastic garbage bags together, wrapped the bags around R3, underneath R3's breast and tied it to the back of R3's wheelchair. R3 was tied to her wheelchair for fifteen minutes. I took the plastic bags off R3 and place them in the second draw behind the nursing station on the right side. On 2/21/23 at 3:30pm, the surveyor requested, V26 (Nurse) to open the second draw on the right side behind the nursing station, two clear white long plastic bags similar to garbage bags were tied together in a knot. On 2/21/23 at 3:40pm, body assessment completed by V20 (Nurse). R3 was observed with a liner redden area located on the upper back to the right of R3's spine. V20 said, R3 did not have that mark on her back yesterday. On 2/21/23 at 4:08pm, R5 who was assessed to be alert and oriented to person, place, and time, said V19 crossed the lines, R3 had to go to the bathroom. V19 grabbed a bag, tied it around R3 waist and tie R3 to her wheelchair. R3 started yelling, stop, stop it. R3 doesn't and won't remember the incident. On 2/21/23 at 5:30pm, the surveyor observed video recording with V1 (Administrator). V1 identified all staff and resident on the screen. The video recording of V19 and R3 was dated 2/16/23 at 4:43pm. R3 was observed in the dining room sitting at a table. R5 was sitting directly in front of R3. R3 attempted to stand up from her wheelchair multiple times. V18 ran to R3. R3 sat back down. V19 took R3 to another table, placed the back of R3's wheelchair to the wall and slid the table up R3's body. R3 was observed with no room to move between the wall and table. V19 left the dinning, returned with a long white plastic bag in hand. V19 wrapped the bag under R3's breast and tied it to the back of R3's wheelchair. On 2/22/23 at 5:19pm, V25 (R3's POA) said, I watch the video with R3 and V19. V19 tied a garbage bag around R3 and tied it to R3's wheelchair. R3 had attempted to stand-up from the wheelchair prior to being tied. I requested for R3 to go to the hospital on 2/18/23. R3 was frightened. R3 looked out of sorts and upset. I was upset about the incident. V19 demeanor on the video, looked angry. On 2/23/23 at 2:06pm, V29 (Medical Doctor) said, I was not informed R3 was restrained with a plastic bag and tied to the wheelchair. No human should be restrained like that. R3 had Dementia and was recovering from a hospitalization with Sepsis. Restraining R3 was not good to do and would have increased R3's agitation and made R3 upset. R3 could have hurt herself. Initial Report dated 2/17/23 documents: V18 (CNA) alleged V19 (Nurse) improperly used restrain. Local police department report dated 2/17/23 at 16:47 documents under nature of complaint: battery. Under narrative: The following is a general summary of my recollection of events and all conversations are not verbatim. In summary dispatched to facility for a complaint of elder abuse. Upon arrival, V1 (Administrator) related that on 2/16/23 V18 (CNA) came into the office and wanted to file a complaint about improper use of restraints on elderly resident. V19 (Nurse) used a piece of plastic to restrain R3's abdomen when she began attempting to stand up during mealtime. V1 further related that V19 admitted to using a piece of plastic to restrain her (R3) abdomen due to not having immediate access to proper abdomen restraint. Video footage was reviewed on 2/18/23 with observations of R3 attempting to stand up multiple times. The third time R3 attempted to stand up, V19 can be seen entering the room visibly upset. V19 returns R3 to the dining room and returns with two (2) clear plastic garbage bags tied together. V19 proceeds to tie R3 around her chest to the wheelchair with two garbage bags. R3's hospital record dated 2/18/23 documents: Family report, he was notified yesterday that patient was restrained using a plastic bag by staff member at the nursing home on Thursday. Skin assessment dated [DATE] documents: redness which measured 1.2 cm (length) X 1.2cm (width) x no depth. Facility policy regarding physical restraints undated documents: In compliance with state and federal regulations, this facility is committed to limiting and reducing the use of physical restraints. The use of physical restraints shall be limited to situations necessary to maximize the resident's physical, mental and psychosocial well-being and to treat the resident's medical symptoms. It shall be the policy of this facility that physical restraints shall not be applied for the purposes of punitive actions against a resident or for staff convenience. Physical restraint means any manual method or physical or mechanical device, equipment or material that meets all the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident (resident is able to remove the device the same manner it was applied to by the facility staff); restricts resident freedom of movement or normal access to his/her body. Convenience means actions taken by the facility to control resident behavior or maintain a resident, is not in the resident's best interest, with less effort or expense than would otherwise be required by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor and recollect a contaminated urine culture sample for a resident with an indwelling catheter and a history of urinary tract infections. This affected 1 of 3 (R1) residents reviewed for physician orders. This failure resulted in R1 who was observed with purulent urine, abnormal urinalysis, and low urine output, being hospitalized for complicated catheter associated urinary tract infection with sepsis present on admission(POA) and pseudomonal bacteremia secondary to urinary tract infection. Findings include: R1 admitted to the facility on [DATE] with a diagnosis of urinary tract infection, multiple scleroses, sepsis, and neuromuscular dysfunction of the bladder. R1's Minimum Data Set, dated [DATE] documents a brief interview for mental status score of 13/15 which indicates cognitively intact. R1's laboratory report dated 1/26/23 documents under urine culture: mixed flora more than 100,000 count. Multiple bacterial morphotypes present, possible contamination. Suggest a recollection if clinically indicated. Urinalysis dated 1/25/23 documents under bacteria many and leukocytes large. R1's nurse practitioner progress notes dated 1/24/23 documents: Patient reports having (indwelling catheter) changed over the weekend due to being dislodged. Nursing notes indicate (indwelling catheter) was changed last night due to leaking. (Indwelling catheter) to gravity, urine purulent, yellow in tubing. Do not change (indwelling catheter) for leaking. Ok to flush if possibly clogged. (Indwelling catheter) only to be changed only monthly or if dislodged. Urinary tract infection-purulent output in (indwelling catheter). Checking urinalysis with culture and sensitivity. R1's nurse practitioner progress notes dated 1/26/23 documents: Patient states that she had (indwelling catheter) changed last night due to leaking. Urine specimen was sent to the lab. Under genitourinary documents: positive leaking. Under assessment and plan: leaking (indwelling catheter) monitor urinary output, urinalysis 1/25 positive for large leukocytes and many bacteria; urine culture showed mixed flora- contamination- will recollect; no leukocytosis, no fever; will educate nursing staff to not exchange (indwelling catheter) every time is leaking; may flush (indwelling catheter) if concerned for clogging. R1's February 2023 medication administration record for (indwelling catheter) output every shift document on 2/4/23 700-300pm shift 350ml, 300- 1100pm shift 100 ml,11-7am shift medium. On 2/5/23 700-300pm shift 200ml, 300- 1100pm shift 60 ml,11-7am shift medium. No documentation for 2/6/23 am shift. R1's progress note dated 2/6/23 at 6:52AM documents: This morning states her abdomen has colic and cramps. Abdomen somewhat distended with some tympany noted. States the last bowel movement when given a shower a few days ago. Positioned to the left side of her body and will request assistance to place her on the commode for relief. R1's progress notes dated 2/6/23 at 3:47PM documents: Writer found the patient with altered mental status, tachycardia, and fever. Referred to nurse practitioner with order to send resident to local hospital for evaluation. Picked up at 1:48PM. R1's hospital record dated 2/6/23 documents under discharge diagnosis: complicated catheter associated urinary tract infection with severe sepsis present on admission (POA), acute metabolic encephalopathy, pseudomonal bacteremia secondary to urinary tract infection. R1's hospital record dated 2/6/23 documents: bed side ultrasound utilized, does have a distended bladder with indwelling foley catheter, concern for urinary retention, possibly clogged foley catheter. Under hospital course side ultrasound, patient does have a significant urine in her bladder. On 2/21/23 at 11:28AM, V2(Assistant Director of Nurses/ADON) said nurse practitioners will verbally inform nurse on duty of any new orders and nurse would be responsible for carrying out the order. V2 said she is not sure what happened and possibly a miscommunication for why R1's urine culture was not recollected. V2 said nurses are responsible for documenting amount of urine at the end of the shift. Urine output 200 ml or less she would expect nurses to check the foley, check for abdominal distention and notify doctor of changes. On 2/22/23 at 10:00AM, V13(Physician) said for R1's urine culture with mixed flora, they would not start treatment but would have re-culture the urine to rule out infection. V13 said he would expect the physician's orders to be followed. V13 said he was not sure and would not be able to determine if the facility's failure of not rechecking R1 urine led to her hospitalization for urinary tract infection and sepsis. V13 said urine output less than 150 ml during an 8-hour shift would be abnormal and would expect to be notified. Facility policy titled Physicians orders revised 5/17 documents: the nursing staff member or the one assigned to the resident is responsible to transcribe the order. Transcribing the order includes completing laboratory requests. For facilities on electronic health records. Orders must be promptly entered into the computer. Facility policy titled catheter insertion and maintenance revised 10/22 documents: to maintain constant urinary drainage based on physician order. Maintain a closed urinary system to prevent introduction of bacteria into urinary tract. Measure drainage at the end of each eight hour shift, if ordered, unless more frequent measurement has been ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their fall policy and plan of care by not using a mechanical lift for transfers. This affected 1 of 3 (R2) residents reviewed for safe transfers. This failure resulted in R2 sustaining a fall with a large hematoma, swollen left knee and an oblique fracture of the proximal tibia that required hospitalization and surgical interventions. Findings Include: R2 was diagnosis with hemiplegia and hemiparesis following cerebral infraction affecting left non-dominate side and history of falling. Brief interview for mental status dated 1/12/23 documents a score of nine which indicates moderately impaired. Section F (functional status) dated 1/12/23 documents: R2 is total dependent with two plus physical assist with transfers. R2 has impairment on one side to the upper extremity (shoulder, elbow, wrist, hand) and impairment on both sides to the lower extremities (hip, knee, ankle, foot). Care plan dated 1/2/23 documents R2 had inability to transfer self and is at risk for ADL decline related to muscle weakness. R2 requires two staff assist with use of mechanical lift for transfers. On 2/17/23 at 12:01pm, R2 who was assessed to be alert to person, place and time said, I was being assisted from my wheelchair to the bed by V8 (Certified Nurse Assistant/CNA) and V10 (CNA). V8 and V10 were on each side of me, both V8 and V10 were holding me under my arm, no gait belt or mechanical device was used. V8 and V10 lifted me up from my wheelchair, I lost my balance and fell. I fell on the floor, on my buttock with my leg bent under my body. On 2/17/23 at 4:08pm, V8 said V10 help me put R2 in bed. V10 lifted R2 from the wheelchair by placing his arms under R2 arms like a forklift. V10 picked R2 up without using a gate belt or mechanical lift. V10 sat R2 up on the bed, R2's legs did not come with R2's body. I grabbed R2's leg and swung them with R2's body. We did not use the mechanical lift due to R2 not having the sling pad under her buttock while sitting in her wheelchair. It would have been impossible to get a pad under R2 while in the sitting position in her wheelchair. We did not use a gait belt either. Anytime, I need to transfer R2 from the wheelchair, I always get help from a male staff member to assist with lifting R2. I have not had any training on transfers or fall prevention. On 2/21/23 at 1:57pm, V15 (Occupation Therapist) said, R2 can't transfer from the wheelchair to the bed without a mechanic lift. A two person assist without a gait belt due to R2's limited mobility and strength would be unsafe. On 2/21/23 at 12:08pm, V27 (Nurse Practitioner) said, an oblique fracture tibia is caused by a direct landing with the knee in a flex position on a hard surface. R2 is dead weight. R2 can't stop or support herself with any momentum. R2 is not a candidate for a two-person transfer. R2 does not have strength. R2 is alert and orient times three (person, place, and time). New Employee (V8) Orientation Check List no date documents: V8's Initial for fall prevention and no trainer initial was documented. Fall risk assessment dated [DATE] documents: R2 is a high fall. R2's fall incident dated 1/21/22 documents: Type: fall Location: resident room, Activity: Transfer: Cognition prior to and after occurrence: Oriented X3. Injuries: Left lower leg skin discoloration: Notes: CNA informed writer that this resident (R2) leg does not look too good. R2's left lower extremity was noted to have increased edema and discoloration. R2 stated, I slipped off my wheelchair yesterday. Transfer form dated 1/21/23- R2 was transferred to the hospital due to left knee swelling and bruising. Hospital papers dated 1/21/23 documents: R2 presented to the emergency room from the nursing home for evaluation of the left knee hematoma that was painful to touch. R2 said, she had a fall yesterday. R2 had left weakness and flaccid, bilateral leg weakness, left knee with large hematoma, and was swollen. Bruising and erythema (redden) present. Knee X-ray dated documents: oblique fracture of the proximal tibia (The proximal tibia is the upper part of the shinbone that connects to the knee joint) extending from the medical margin superior. Preoperative diagnosis documents: Left displaced medial tibial plateau fracture, left displace tibial tubercle fracture with patellar tendon avulsion (tendon rupture) and left lower extremity hematoma with skin threatening. Procedure performed was an open reduction and internal fixation left tibial plateau, open reduction and internal fixation left tibial tubercle and incision and drainage of deep hematoma left tibia. Fall policy dated 10/2022 documents: It is the policy of the facility to have a fall reduction program that promotes the safe of resident in the facility. The program's intent is to assist clinical staff in determining the needs of each resident through the use of standard assessment, the identification of each resident's individual risks, and the implementation of appropriate interventions, supervision and/or assistive device deemed appropriate. Example of standard fall/safety precautions that may be applicable. #1. Staff will be oriented and trained in the fall reduction program. #12. Transfer conveyance shall be used to transfer resident in accordance with the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident's negative pressure wound therapy machine was continuously on when applied to a pressure wound for 1 of 3 residents (R5) reviewed for pressure wounds in the sample of 9. This failure resulted in R5 developing an infected pressure wound and sent the hospital. The findings include: R5's Face Sheet shows that he was admitted to the facility on [DATE]. R5's hospital After Visit Summary does not show a medication order for antibiotics on admission. R5's Wound Management Detail Report dated 12/22/22 shows that R5 had a stage 4 sacrum ulcer measuring 11 centimeters (cm) x 8 cm x 2 cm that had a heavy amount of serosanguineous drainage (clear/bloody draining that is present in a healthy healing wound) with no odor present. R5 had a negative pressure wound therapy (wound V.A.C) machine attached to the wound. R5's Physicians Order Sheet shows an order dated 12/22/22 for, Site: Sacrum-cleanse area with noncytotoxic wound cleaner, pat dry, apply skin prep, drape, black foam to wound bed, drape, connect the wound vac at 125 mmHg continuous suction. May use Dakins soaked gauze and foam or bordered gauze if wound vac seal is not achievable. R5's Nursing Notes dated 12/26/22 at 10:47 AM shows, Wound care update-Upon assessment of sacral wound I observed there was no seal and the wound vac dressing was completely soaked, wound bed had a foul odor, erythema on peri wound and maceration, NOD (nurse on duty) reported she turned the machine on this am. On 2/10/23 at 9:30 AM, a wound V.A.C machine was observed in a resident room. The machine had a note on it that said, Do not turn this machine off. On 2/10/23 at 12:00 PM, V18 (Licensed Practical Nurse) said that she worked on 12/26/22 the day shift. V18 said that during her morning rounds she went into R5's room and it smelled horrible. V18 said that she checked the wound V.A.C machine and it was off. V18 said that she then turned the wound V.A.C machine on and notified the wound nurse. On 2/10/23 at 11:15 AM, V4 (Wound Registered Nurse) said that wound V.A.Cs are never to be turned off unless the dressing is being changed. V4 said that she has notes on each machine that says to not turn them off. V4 said that wound V.A.Cs can only be left off for about 2 hours before the resident is at risk for infections, drainage accumulation and wound deterioration. At 11:35 AM, V4 said that she came in Monday morning (12/26/22) and the day shift nurse said that they were having issues with the machine beeping and she turned it on when she came in. V4 said that she asked her how long the V.A.C had been turned off and the nurse did not know. V4 said that the nursing staff is directed to call her if the machine is beeping and if she cannot attend to the machine right away, the machine should be removed and a wet to dry dressing should be placed on the wound until she can re-apply the wound V.A.C. R5's Wound Culture Report dated 12/28/22 shows there was heavy growth of Escherichia coli and moderate growth of Enterococcus species present. R5's Nursing Notes on 12/30/22 show, Relayed wound culture lab results to [Nurse Practitioner], with order to send resident out for further evaluation due to worsening infection to sacral wound. On 2/10/23 at 12:15 PM, V19 (emergency room Registered Nurse) said that R5's emergency room Report from 12/30/22 documents that he arrived at the hospital with a 15 cm x 15 cm sacral wound that had purulent draining (white/yellow drainage that is a sign of infection) and a foul odor present. R5's Care Plan dated 12/27/22 shows, [R5] is currently receiving negative pressure wound therapy due to pressure ulcer [R5's] ulcer will not increase in size. Ulcer will not exhibit signs of infection .Confirm the unit is on and set the appropriate negative pressure settings, that the foam is collapsed and NPWT device is maintaining the prescribed therapy and pressure. Address and resolve alarm issues If seal the seal is broken, or alarm is [sic] does not resolve remove and apply moist dressing and notify MD (Medical Doctor). The facility's undated (brand name) Negative Pressure Wound Therapy Quick Reference Card shows, Warning alarms need to be addressed as soon as possible. The therapy is stopped or lessened as long as the cause of the alarm is not corrected. If you are unable to correct the cause of the alarm, contact the physician for instructions. If you are unable to reach the physician, contact an emergency room for assistance .Failure to obtain and follow instructions from the treating physician could result in injury or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R3 was admitted to the facility on [DATE] with diagnosis including but not limited to bipolar disorder, History of Falls, Scoliosis, Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, Age-related osteoporosis without current pathological fracture, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. According to MDS (Minimum Data Set) dated 09/30/2022 under Section C, R3 has a BIMS (Brief Interview of Mental Status) score of 6 indicating severely impaired cognitive functioning. On 12/19/2022 at 11:23 AM the surveyor observed R3 sitting in the wheelchair in the common area, participating in the activities at this time. On 12/19/2022 at 11:23 AM the surveyor asked R3 about her fall incident on 10/17/2022, R3 stated, Where did it happen? Surveyor clarified that R3 suffered a fall at the facility where she currently resides. R3 stated, Oh yes, I think I fell and hurt my hip but it's all better now. Not sure how it happened. I don't remember what happened after that. Surveyor unable to interview R3 due to R3's severe confusion. Per record review, incident report with occurrence date of 10/17/2022, reads in part, At approximately 5:00 PM on October 17th, 2022, nurse (V10 Licensed Practical Nurse) was notified by Certified Nursing Assistant that R3 had fallen in her room. R3 complained of mild pain to the right hip. Medical doctor notified with order for stat x-ray of right hip and pelvis. At approximately 11:40 AM on October 18th, 2022, x-ray results of right hip and pelvis received and revealed a fracture of the right femoral neck. V14 (Nurse Practitioner) made aware with order to send to hospital's emergency department for further evaluation and treatment. Per record review, progress note dated 10/17/2022 at 9:58 PM written by V10 (Licensed Practical Nurse) reads in part, [V10 (LPN)] was informed by the duty Certified Nursing Assistant that R3 is sitting on the floor near the edge of the bed. [V10] Conducted physical assessment, R3 [displayed] little discomfort to her right hip. Primary doctor was informed and ordered right hip x-ray; order was carried out. Per record review, radiology order dated 10/17/2022 at 9:13 AM reads in part, Order description: Rt Hip, STAT - Immediately. Per record review, outpatient medical diagnostic service company radiologic order dated 10/17/2022, reads in part, Study description: R-hip with Pelvis; reported date and time: 10/18/2022 12:06 AM; Impression right hip: impacted transcervical fracture of the right femoral neck with varus deformity. Per record review, ambulance report dated 10/18/2022 reads in part, Ambulance at scene 10/18/2022 at 1:37 PM. Emergency medical crew assessed vital signs at this time which revealed several emergent findings. Per record review, surveyor noted ambulance arrived approximately 20 hours after R3 suffered fracture to the right hip. Per record review, hospital record dated 10/19/2022 at 7:50 AM, reads in part, R3 presented to emergency department after fall. Diagnosed with right hip fracture and urosepsis. Patient has right hip pain. Per record review, operative note dated 10/20/2022 reads in part, R3's pre-op diagnosis: right hip fracture; Procedure: Hemiarthroplasty Right Hip; Findings: Displaced comminuted femoral neck fracture. Per record review, surveyor noted that R3's right femoral fracture went from an impacted fracture to a displaced fracture between 10/17/2022 and 10/20/2022. On 12/19/2022 at 2:23 PM the surveyor interviewed V2 (DON). V2 (DON) stated, Stat order should be carried out within 4-6 hours from the time when it was received. Outpatient diagnostic services company provides all of our x-ray needs, including regular and stat. When a nurse becomes aware that stat x-ray is needed, he or she should put the order into electronic health record system and call the outpatient diagnostic services company to make sure they received the order. Outpatient diagnostic services company should come withing 2 hours from the time when they receive our stat order. On 12/19/2022 at 3:33 PM the surveyor interviewed V10 (Licensed Practical Nurse/LPN). V10 (LPN) was a nurse on duty upon R3's fall. V10 (LPN) stated, R3 suffered a fall on 10/17/2022 around 5:00 PM. Once the fall was reported to me, I performed an assessment and R3 expressed that she has some pain in the right hip area. I called the doctor and suggested that we should do a stat x-ray. I proceeded to put the order into electronic health record system for stat right hip x-ray and called outpatient diagnostic services company to ensure that they received the order. I didn't see them before end of my shift at 11:00 PM. Per record review, progress note dated 10/18/2022 at 12:02 AM written by V10 (LPN) reads in part, R3 was x-ray on her right hip, waiting for results. Discrepancy in V10's (LPN) interview and progress note noted. On 12/20/2022 at 10:00 AM the surveyor interviewed V11 (LPN). V11 stated, I worked night shift from 10/17/2022 to 10/18/2022 from 11:00 PM to 7:00 AM. I don't remember seeing outpatient diagnostic services company come out on my shift. I knew that the resident suffered a fall in the afternoon of 10/17/2022 and was waiting for an x-ray. I called around 4:00 AM on 10/18/2022 to follow up with outpatient diagnostic service company and they said that they will send somebody out; however, I didn't see anyone before the end of my shift at 7:00 AM. I did not chart that I made a follow up call. Per record review, progress note dated 10/18/2022 at 11:40 AM written by V16 (LPN) reads in part, [R3's right lower extremity] shortened and externally rotated. Per V2 (DON), V16 (LPN) did not answer the phone and V2 feels that she should not provide contact number to surveyor without V16's approval. Unable to interview V16 (LPN). On 12/20/2022 at 12:11 PM the surveyor interviewed V14 (Nurse Practitioner). V14 (NP) stated, I found out about R3's fall on 10/18/2022 around 9:30 AM during team's morning meeting. I went up and checked on R3. R3 didn't complain of any major discomfort, only mild pain to her right hip that was treated with in-house pain medication. There were no x-ray results available at that time. I spoke to V16 (Licensed Practical Nurse) around 11:00 AM, and we called outpatient medical services company; we received results over the phone, and they also faxed them to the facility around that time. The surveyor asked if delay in receiving x-ray results of R3's hip could have a negative outcome on her injury. V14 (NP) stated, R3 needed an orthopedic evaluation to determine appropriate treatment. Supposedly, R3 was at a higher risk for blood clot formation due to fracture. On 12/20 2022 at 12:42 AM the surveyor interviewed V2 (DON). V2 stated, I just spoke to outpatient medical services company that performed R'3 x-ray on the night of 10/17/2022- 10/18/2022. They informed me that they faxed results on 10/18/2022 at 1:11 AM to a number that doesn't belong to our facility. Surveyor asked how did V2 (DON) find out about R3's missing hip x-ray results. V2 (DON) stated, On 10/18/2022 at 9:30 AM, during team meeting, we realized that there was no follow up of R3's fall and that's when V14 (NP) and V16 (LPN) called outpatient medical services company to follow up on R3's hip x-ray results. Surveyor clarified what could V11 (LPN) have done to prevent delay in receiving R3's stat x-ray results. V2 (DON) stated, V11 could have reached out to me to notify me that R3's x-ray was done but no results were reported. I could have tried to get R3's results myself. Our nurses are aware of urgency of stat results; however, I can't speak for the agency nurses. No stat order facility policy available upon request per V2 (DON). Based on observation, interview, and record review facility failed to provide emergency diagnostic services and failed to follow up and relay emergency diagnostic services' results to medical practitioner. The facility also failed to administer three out of four seizure medications for two (R3, R4) out of two residents reviewed for quality of care in the sample of 11. These deficiencies resulted in R3's delayed treatment of right hip fracture with subsequent right hip surgery and R4's hospitalization due to multiple seizures. Findings include: 1. R4 admitted to facility 12/02/2022 and has past medical history not limited to: Epilepsy, Metabolic Encephalopathy, Other specified postprocedural s/p craniotomy, Cerebral Ischemia, Other cervical disc degeneration (unspecified cervical region), Presence of cerebrospinal fluid drainage device s/p shunt, and Spinal stenosis (cervical region). Reviewed R4's facility transfer/discharge summary that showed on 12/04/2022, R4 was transferred to the emergency room as a result of having multiple seizures while at facility. No care plan found in R4's electronic medical record. Progress Note dated 12/04/2022 04:32 PM showed facility called hospital for follow up. Nurse stated that resident has been admitted with diagnosis of seizure. Progress Note dated 12/04/2022 04:30 AM showed, Pt began seizing @0345, lasted for 1.5 minutes. After seizure pt (patient) eyes open to stimulus but was not responding as usual. VS BP 129/84 P 134 RR 20 O2 93% BS 150. Pt began seizing again 2 minutes apart for 2.5 minutes. Called primary physician regarding findings and was advised to send pt to local emergency per nurse practitioner order. Pt was sent via fire department @0400. DON (Director of Nurses) notified. Nurse Practitioner aware. Emergency contact notified; SMS VM left with call back number and extension. Gave report to [nurse] in ER. Reviewed R4's active physician orders from 12/02/2022-12/04/2022 (upon discharge) that showed orders for the following anti-seizure medications: clobazam (Schedule IV) 10 mg tablet via gastric tube twice a day 09:00 AM, 04:30 PM; levetiracetam solution 100 mg/mL amt:20mL via gastric tube every 12 hours 09:00 AM, 09:00 PM; phenytoin suspension 125 mg/5 mL amt:10mL via gastric tube twice a day 06:00 AM, 06:00 PM; Vimpat (lacosamide) (Schedule V) 200 mg tablet via gastric tube every 12 hours 09:00 AM, 09:00 PM. Reviewed R4's medication administration record from 12/01/2022-12/20/2022 that showed R4 was not administered 3 of 4 scheduled seizure medications while at the facility as follows: R4 was not administered clobazam (Schedule IV) 10 mg tablet at 04:30 PM on 12/02/2022 and at 09:00 AM and 04:30 PM on 12/03/2022. Total of 3 missed medication administrations. R4 was not administered phenytoin suspension 125 mg/5 mL (10mL) at 04:30 PM on 12/02/2022. Total of 1 missed medication administration. R4 was not administered Vimpat (lacosamide Schedule V) 200 mg tablet at 09:00 PM on 12/02/2022, at 09:00 AM and 09:00 PM on 12/03/2022. Total of 3 missed medication administrations. R4's medication administration record from 12/01/2022-12/20/2022 also showed that R4 was not administered warfarin 6mg (anticoagulant) at 04:00 PM on 12/02/2022. Documented reasons all showed not administered: drug/item not available. On 12/20/2022 at 2:44 PM, V2 (Director of Nursing) said her expectations regarding medication administration is for nurses to administer medications as prescribed within the 1-hour window before and after its scheduled time. V2 then said if a medication is unavailable, nurses should check in the facility's automated medication dispensing system first to see if medication is available for administration, then call the pharmacy to inquire why medication is not available and can do a stat (emergency) order. When asked if a resident's physician should be contacted, V2 said she was unsure of their policy on how many missed doses warrant contacting the physician. V2 also said nurses should document the missed medication and any correspondence with pharmacy and the resident's physician within their medical record. At 2:48 PM, V2 said the facility has several consistent agency staff who are coming in to help fill staffing holes. When asked what the process is when an agency nurse comes into facility, V2 said they receive a brief one-time orientation. Requested facility policy for contract staff, none provided during course of investigation. Requested facility policy for missed medication administration, none provided during course of investigation. Requested list of medications stored within the facility's automated medication dispensing system. None provided during course of investigation. Reviewed facility's medication administration policy last reviewed 05/17 that showed: Objective: To document the administration and ordering of those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. Procedure: All Medications must be administered to the resident in the manner and method prescribed by the physician. In the event that a medication cannot be given, the reason must be documented in the Nurses Medication Notes on the MAR or Progress Notes. Documentation of meds given will be done in a consistent manner by the nurse placing their initials in the appropriate space on the MAR.