**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe mechanical lift transfer for 1 of 1 resident (R1) reviewed for falls in a sample of 12. This failure resulted in R1 becoming scared she would fall and anxious during the transfer and becoming afraid of of future mechanical lift transfers. Findings include: R1's Face Sheet documented an admission Date of 7/6/23 and listed Diagnoses including Chronic Obstructive Pulmonary Disorder, Diabetes Type 2, and Anxiety disorder. R1's Care Plan dated 8/20/24 documented problem areas,I have an ADL (Activities of Daily Living) self-care/ mobility performance (functional abilities) deficit, and, I use anti anxiety medications. R1's Minimum Data Set, dated [DATE] documented that R1 has minimal deficits in cognition and is totally dependent on staff for transfers. On 9/17/24 at 10:55am, R1 was alert and oriented to person, place, and time. R1 stated that on the morning of 9/16/24, V4, Certified Nursing Assistant, was getting her out of bed and ready for a doctors appointment. R1 stated she had two family members present at the time. R1 stated V4 transferred R1 out of the bed into the wheelchair via mechanical lift. R1 stated V4 was the only staff member present during the transfer. R1 stated, Thank God those two (V10, V11, family members) were in the room to help because I about got dumped out of the (lift) sling. I don't think (V4) knows how to use a (mechanical lift). R1's was upset and distressed while discussing this. R1 stated she was extremely upset and scared that she was going to be dumped out of the sling. R1 stated now she is scared for staff to transfer her via mechanical lift and that is the only way for her to be transferred out of the bed. On 9/17/24 at 1:00pm V10 stated she was present during the above referenced transfer. V10 stated she and V11 assisted V4 with the transfer as V4 was the only staff member present. V10 stated she and V4 stood at the wheelchair while V11 worked the controls on the mechanical lift. V10 stated V4 was giving the directions about what to do. V10 stated the mechanical lift started heavily leaning to one side and R1 was hovering over the wheelchair in a nearly laying down position. V10 stated V10 and V11 got R1 under the arms and lowered R1 into the chair. V10 stated R1 was, Upset and scared to death. On 9/18/24 at 1:50pm, V4 corroborated R1 and V10's accounts of the transfer as stated above. V4 stated they were short staffed that day, and she could not find any staff to help with the transfer so V10 and V11 assisted, with V11 working the controls. V4 stated later V4 was called in by administrative staff because R1 told others about what happened and that she was scared. V4 stated,They told me next time if I cant find somebody come get administrative staff. On 9/19/24 at 12:50pm, V2, Director of Nurses, stated the incident with R1's transfer had come to her attention and she talked to V4 about it. V2 stated V4 said she couldn't find anybody to help, and was told to ask administrative staff to help next time. V2 confirmed it is against facility policy for there to be fewer than 2 staff members present and for family members to assist with a mechanical lift transfer. V2 stated she did not complete an incident report. A Mechanical Gait Belt and Mechanical Lift Policy dated 11/28/12 documented,The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H: Mechanical lift (trade name) with 2 caregivers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and evaluate potential hazards/risks and implement interventions to ensure safe transfers via mechanical lifts for 1 (R1) of 3 residents reviewed for accident hazards and injuries of unknown origin in the sample of 6. This failure resulted in R1 sustaining injuries of bruising to the tops of both feet and a hematoma under the nail of the right great toe. Findings include: R1's Face Sheet documented an initial admission date of 7/23/20 with diagnoses that included unsteadiness of feet, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, and cerebrovascular disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R1 had moderate cognitive impairment. On 8/23/24 at 1:00 PM, R1's right great toenail was black with blood under the nail. R1's feet had greenish yellow bruising to the tops of both feet measuring approximately 3 inches x 3 inches. R1 stated he did not know how his feet had been injured. R1's Hospice Visit Note dated 7/26/24 documented R1 did not have any bruising to the feet. R1's Hospice Visit Note dated 7/29/24 documented in part .Rt. (right) foot and leg was swollen and had bruises present, SNF (Skilled Nursing Facility) reported no falls or injuries for (R1) . R1's Hospice Visit Note dated 8/2/24 documented in part . Lt (left) foot has a bruise on the top of foot size of a softball circle with purple/green in color. (Right) leg was swollen around ankle bone and had bruises present on top of the foot and side of ankle with purple/green bruise. SNF reported no falls or injuries . reported these findings to (V2 - Director of Nursing/DON). Pt (patient/R1) is unaware of how or when the bruise occurred . SN (Skilled Nurse) left a message with person answering (facility) work phone for Nurse on staff to give me a call, as SN needs a report of unknown bruise noted as staff nurses had not document on BLE (Bilateral Lower Extremities) having any bruise. (V7 - Registered Nurse/RN) on staff at SNF was not present during any SNV (Skilled Nurse Visit) and SN was unable to give (V7) report as no staff could find (V7) . R1's Hospice Visit Note dated 8/5/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V13 - Licensed Practical Nurse/LPN) and (V7) and stated SN needed a incident report since they have no report filled out stating that SNF staff has seen or document pt (R1) having bruises to BLE. Staff is supposed to write up a report stating that bruise are from unknown causes, both (V7) and (V13) voiced understanding . R1's Hospice Visit Note dated 8/9/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V5/LPN) and (V2/DON). SN stated hospice needed a incident report since they have no report filled out stating that the SNF staff has seen or document (R1) having bruises to BLE. Staff was suppose to write up a report stating that bruise are from unknown causes, both (V7) and (V13) voiced understanding at last SNV and no report can be found or has been filled out per (V5) and (V2). (sic) Per (V2) a report will be filled out and SN can obtain a copy from them next week . R1's Hospice Visit Note dated 8/12/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V3 - Assistant Director of Nursing/ADON) SN stated hospice needed a incident report since they have no report filled out stating that the SNF staff has seen or document (R1) having bruises to BLE. Staff was suppose to write up a report stating that bruise are from unknown causes, report is filled out but is not signed by any of the nurses yet . R1's Hospice Visit Report dated 8/16/24 documented in part .SN received report from (V17- Hospice Certified Nursing Assistant/CNA) that (R1) had bleeding to (right) great toe and bruising noted around toe nail bed. (R1's right) great toe has blood under toe nail bed . with bruising around nail bed noted. SN spoke with (V2) and (V3) and per them 'assessed toe d/t (due to) Hospice aide (V17/CNA) reported findings to (V2) and (V3)' . No reports noted of pt (patient) fall or injury noted per staff records. SN is still unable to get report from SNF of bruise noted on 8/2/24 as per (V2) and (V3) 'note is not signed yet' . R1's Hospice Visit Note dated 8/20/24 documented in part .brusied [sic] noted to Rt. great toe with dried blood under nail bed. SN reported SN findings to (V7/RN). SN still does not have report from 8/2/24 as it still not signed by RN .MD is aware of SN and CNA reporting SNF to (State Agency). R1's Electronic Medical Record (EMR) documented two progress notes on 8/11/24 that had been struck out citing incorrect documentation: R1's struck out progress note dated 8/11/24 at 1:58 AM documented in part Note Text: (R17) Follow up assessment completed. Bruising to top of left, right foot .reddish purple bruising noted . The note documents Strike Out Reason: Incorrect Documentation and Strike Out date: 8/14/24 09:05 (am). R1's struck out progress note dated 8/11/24 at 9:25 AM documented in part Note Text (R17) Follow up assessment completed. Bruising to top left of right foot .No skin issues noted. No Bruising noted. No s/s (signs/symptoms) of infection noted to site. No swelling noted. The note documents Strike Out Reason: Incorrect Documentation and Strike Out date: 8/14/24 09:05 (am). On 8/23/24 at 10:59 AM, V4 (Hospice RN) stated R1 had bruising found on 8/2/24 to the top of both feet about the size of a softball. V4 said she had reported the bruising to V2 (DON) when V4 found the bruising. V4 said that on 8/5/24, V4 had returned to the facility and V7 (RN) and V13 (LPN) said they were not aware of R1 having any injuries. V4 stated that on 8/9/24, she told V2 that V4 would need a report on the bruises because the staff could not tell V4 how R1 was injured and there was no documentation of the bruising in R1's medical record. V4 then stated that on 8/16/24, R1 was found to have bleeding and a hematoma under the right great toenail with surrounding bruising to the toe. V4 said the facility was not able to explain how R1's right great toe was injured. V4 said she had asked the facility several times for a report on R1's injuries of unknown origin but none had been provided. On 8/23/24 at 11:31 AM, V2 (DON) said staff would use the mechanical lift to transfer R1 when R1 was not feeling strong enough to stand for transfers. V2 said she thought the injuries to R1's feet had been caused by staff hitting R1's feet on the bar of the mechanical lift. On 8/27/24 at 11:00 AM, V16 (CNA) stated that the facility had several agency staff who don't care, and will hit resident's feet on the bar of the mechanical lift when transferring them. At the same time of this interview with V16, this surveyor observed a dark red substance that appeared to be dried blood on the center bar and central cross bar of the mechanical lift. On 8/27/24 at 11:11 AM, V1 (Administrator) verified the dark red substance found on the mechanical lift looked like blood. R1's Report to (State Agency) dated 8/28/24 documented in part .Interviews with staff revealed that resident is tall, a maximum assist, dependent with care. Resident is transferred by 2 staff or at times has had to use a (mechanical lift). Staff stated (R1) has bumped feet on (mechanical lift) before. Staff interviews revealed that resident has been observed to also attempt to self transfer, pulls rolling wheelchair toward him .Interview with (R1) revealed that (R1) was unable to tell me what happened but he could tell me he was alright and having no pain in feet . The facility's revised 10/24/22 Abuse Prevention and Reporting - (State) policy documented in part .Employees are required to report any incident, allegation or suspicion of potential abuse . they observed, hear about, or suspect to the administrator, or to an immediate supervisor who must immediately report it to the administrator .Upon learning of the report, the administrator .shall initiate an incident investigation .Injuries of Unknown Source .For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person orther source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury .or the number of the injuries observed at one particular point in time .If classified as an injury of unknow source, the person gathering the facts will document the injury, the location and time it was observed, any treatment given and notification of the resident's physician, responsible party .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R45's Transfer/Discharge Report dated 5/22/24 documents an admission date of 04/16/21 with diagnoses in part of Cognitive Communication Deficit, Dysphagia, Alzheimer's Disease, Lack of Coordination and Contracture of left hand. R45's MDS dated [DATE] documents in Section C a BIMS score of 0, indicating R45 was unable to complete the BIMS. Staff assessment for mental status was completed and documents short term memory problems and long-term memory problems with moderately impaired decision making, which indicates that R45 makes poor decisions. Section GG documents R45 requires supervision or touching assistance with eating. R45's Care Plan undated, documents an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Alzheimer's disease process. Interventions for eating include in part, R45's usual performance is substantial or maximal assistance. R45 is able to consume regular consistency foods .provide diet as ordered R45's Physician Orders document an order dated 11/29/23 of nutritional ice cream supplement with lunch and dinner and resident (R45) to have house stock nutritional supplement TID (Three times a day) with meals. An order dated 1/28 24 documents general diet mechanical soft texture, regular consistency, nutritional supplement TID (3 times daily), and nutritional ice cream at lunch and supper. On 05/20/24 at 1:15PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/21/24 at 12:20PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/22/24 at 12:20PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/29/24 at 11:10 AM, V29 (Registered Dietician) stated, she would expect all supplements and fortified foods that were ordered to be served as ordered. The dietary policy dated 2020 titled, Fortified Food, Supplements, and Snacks documents: Residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for Fortified Foods, snacks or supplements in order to increase nutritional intake. Commercially prepared supplements and nutritional interventions may be ordered by the food service manager, dietician, or nursing staff. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order and may be substituted with nutritionally equivalent interventions if a specific brand or type of supplement in unavailable. The facility policy titled, weights dated 10/17/19 documents: 3. Re-weight should be obtained if there is a difference of 5# (pounds) or greater (loss or gain) since previously recorded weight. 4. Re-weight should be taken as soon as possible after an unanticipated weight change is noted and prior to calling the physician. (Usually within 72 hours). 5. Efforts should be made to obtain all weights and re-weights by the 10th of each month. 6. Undesired or unanticipated weight gains/loss of 5% in 30 day, 7.5% in three months, or 10% in six months shall be reported to the physician, dietician and/or dietary manager as appropriate. Based on observation, interview and record review, the facility failed to provide additional nourishment as ordered in the form of nutritional supplements and fortified foods for five (R50, R31, R36, R44, and R45) of 12 residents reviewed for nutrition in a sample of 38. This failure resulted in R50 experiencing a significant weight loss of 17.5% in 3 months, and R31 experiencing a significant weight loss of 6.68% in 1 month or 8.58% in 3 months. Findings Include: 1. R50's Transfer/Discharge report documents an admission date of 01/26/24 with diagnoses including: Alcohol abuse with alcohol induced mood disorder, Alcohol Dependence with alcohol induced persisting dementia, Cognitive Communication Deficit, Unspecified Dementia, Wernicke's Encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), and Mood Affective Disorder. R50's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. R50's MDS section GG documents eating ability as: supervision or touching assistance - helper provides verbal cues and or touching/steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R50's Order Summary Report documents orders including: general diet: Regular texture, regular consistency, fortified foods with meals, ice cream with lunch and supper with a start date of 01/26/24, no end date documented; and house nutrition supplement - three times a day in between meals with a start date of 05/16/24 and no end date listed. R50's Care Plan documents a Focus Area dated 03/05/24 documenting: R50 has a nutritional problem or potential nutritional problem regarding the diagnosis of Dementia, Wernicke's Encephalopathy, COPD, and Mood Affective Disorder. R50's care plan documents interventions of: Administer medications as ordered. Monitor/Document for side effects and effectiveness, Encourage PO (by mouth) intake of meals and snacks, Invite the resident to activities that promote additional intake, Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated, provide, serve diet as ordered. Monitor intake and record with meal, and RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed), all interventions are dated 03/05/24. R50's Electronic Medical Record (EMR) documents weights as: 162.8 pounds (lbs.) on 01/26/2024, 161.4 lbs. on 02/07/2024, 161.0 lbs. on 3/18/2024, 139.5 lbs. on 4/9/2024, and 133.0 lbs. (pounds) on 5/15/2024. The weights documented indicate a 17.6 % weight loss in 3 months. On 05/20/24 at 11:00 AM, V22 (Cook) made mashed potatoes with creamy classic mashed potatoes and hot water. No fortified potatoes were observed to be prepared. The recipe titled power potatoes documents ingredients: milk 2%, milk non fat dry, potato, mashed instant, sour cream, margarine, and salt. On 05/20/24 at approximately 12:00 PM during lunch service, there was only one pan of mashed potatoes on the steamtable. Regardless if dietary cards listed fortified potatoes, the creamy classic mashed potatoes were observed to be served to all residents. On 05/20/24 at 12:40 PM, R50 did not receive fortified potatoes or ice cream with his lunch tray. On 05/20/24 at 1:30 PM V16 (Dietary Manager) stated the nutritional supplements came in on the truck that morning and they are frozen, they will have to give them out at snack time. On 05/20/24 at 2:00 PM, V22 (Cook) stated that the mashed potatoes that were made for lunch were made with the potato flakes and hot water, and they were the only potatoes made and served that day. On 05/20/24 at 2:40 PM, V28 (Activity Aide/Certified Nurse Aide/CNA) passed afternoon snacks. On this date between 2:30 - 3:15 PM, R50 did not receive the ice cream during snack time. On 05/21/24 at 12:40 PM, R50 did not receive ice cream with his lunch tray. .At 2:35 PM, R50 did not receive ice cream during snack time. On 05/22/24 at 1:00 PM, R50 did not receive ice cream with his lunch tray. On 05/22/24 at 1:25 PM, R50 had eaten all of the food on his plate and R50 started reaching out for other residents' food. V28 (Activity Aide/CNA) was assisting R28 with her lunch. V28 attempted redirecting R50 and telling him it was not his food. After several attempts at redirecting and R50 starting to get aggressive, V28 asked R50 if he was still hungry and R50 answered yes. V28 went to the snack room and placed some cheese puffs onto a small plate and brought them back for R50. On 05/22/24, R50 did not receive ice cream during snack time. On 05/29/24 at 11:10 AM, V29 (Registered Dietician) stated she was aware of R50's weight loss between March and April and on 04/26/24 she noted she had requested a re-weigh for R50. V29 stated, in her note from 05/16/24, May's weight was consistent with April's weight and she ordered the supplements for R50. 2. R31's Face Sheet documents an admission date of 07/23/20 with diagnoses in part of Heart Failure, Type 2 Diabetes Mellitus, Malignant Neoplasm of Prostate, Hypertension, and Hyperlipidemia. R31's MDS dated [DATE] documents in Section C a BIMS score of 12, which indicates moderate cognitive impairment. Section GG documents that R31 requires set-up and clean-up assistance with eating. R31's Care Plan dated 05/02/24 documents R31 has an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) a diagnosis of CHF (Congestive Heart Failure), DM (Diabetes Mellitus), AFIB (Atrial Fibrillation), MDD (Major Depression Disorder) and HTN (Hypertension) with interventions in part of Eating- My usual performance is set-up. Risk for Depression/Decreased appetite. R31 able to consume regular consistency food with interventions of Monitor and record intake q (Every) shift, monitor for sign/symptoms of aspiration, monitor weight as indicated monthly and PRN (as needed), position for eating and drinking safely, provide diet as ordered, regular diet with super cereal, nutritional shakes with meals as desired, and refer to ST (Speech Therapy) R31's Weight summary in part documents the following weights: 12/21/23 - 200 lbs., 01/17/24 -197.5 lbs., 02/17/24 - 197 lbs., 3/18/24 - 196 lbs., 4/18/24 - 193 lbs., and 05/20/24 180.1 lbs. R31 has had a 6.68% weight loss in 1 month from April to May and 8.58% weight loss in 3 months from February to May. R31's Physician Order documents general diet, regular texture, thin consistency, house nutritional supplement with meals ordered 01/04/24. R31's Nutritional Progress note dated 04/28/24 documents RD (Registered Dietitian) consult for -5.0% change (Comparison Weight 03/30/2024, 195.4 Lbs., -5.1%, -9.9 Lbs. April. Wt. (weight) 186# BMI (Body Mass Index) 34.2 overweight per standards. On 05/20/24 at 11:30 AM, R31 was sitting in the Dining Room in his wheelchair falling asleep at the lunch table. At 12:30 PM, R31 was still sleeping at the lunch table, still waiting on a lunch tray. At 12:33 PM, R31 was taken out of the dining room and placed in the hallway with no tray served to him. At 1:52 PM, R31 was placed in his recliner in his room. At 1:58 PM, V7 (Certified Nurse Assistant/CNA) was asked if R31 had received a lunch tray yet. V7 stated that she was unsure if R31 had eaten yet. At 1:59 PM, V7 looked on the hall tray cart and was unable to find a tray with R31's kitchen card on it. At 2:00 PM, V7 went to the kitchen and asked kitchen staff about R31's lunch tray. V7 stated that the kitchen staff told her they had lost R31's lunch ticket and that they did finally find it. At 2:05 PM, V7 went to R31's room to ask R31 what he would like to eat and R31 stated he would like some soup and crackers with a drink. At 2:15 PM, R31 was served a lunch tray by V7. R31's Order Summary dated 05/21/24 documents send to local hospital emergency room r/t (related to) decline in condition no appetite and lethargy. R31's Progress note dated 05/21/24 at 5:02 PM documents in part, Patient (R31) is going to be admitted to local hospital with dx (diagnosis) of hyponatremia, hypercalcemia and AKI (Acute Kidney Infection). On 05/28/24 at 11:00 AM, V16 (Dietary Manager) stated that she found out last week that the program she uses to print meal tickets wasn't printing off all the meal tickets. V16 said some of the residents' meal tickets were missing. V16 stated that this is the main way they serve residents their meals, by the meal tickets, so if one was missing, they didn't know to serve that resident. V16 said that when she found out the program wasn't printing all of the resident meal tickets, she started to double check to make sure they were all there. V16 said that she must go in and manually print just one or two resident tickets sometimes on her own if they didn't print up with all the other residents' meal tickets. V16 stated sometimes residents can also get missed during mealtimes if a meal ticket gets stuck together. V16 said that she is working on trying to get a better system going so they don't miss any meal tickets or residents' trays. V16 said she wasn't aware of residents missing nutritional supplements last week. V16 said they were very short last week and that could be the reason many of the supplements were forgotten. V16 said that usually the supplements, such as the nutritional shakes and nutritional supplement ice cream comes out of the kitchen served on the tray and the person serving should double check the ticket to make sure that it is correct. V16 said they didn't have a lot of staff last week, she even had to work in the kitchen on 05/23/24 because she was short staffed. V16 stated that she knows that R31 is on a nutritional supplement and doesn't know why he didn't get the supplement or why they forgot his tray. On 05/28/24 at 11:54 AM, V29 (Registered Dietitian) stated she was not aware that R31 was not served a tray on 05/20/24 until staff had to ask for one. V29 stated that she was not aware of V16 having trouble with not being able to print all the residents' meal tickets out and that some of the residents' tickets would be missing and they may not be served a tray. V29 stated R31 was to receive a nutritional supplement with meals related to him having a weight loss. V29 said R31 would take the supplement sometimes, but other times he would refuse them. V29 said R31 was on comfort care and that they offer R31 supplements as he desires. V29 said she knew R31 has recently had a 5% weight loss in a month. V29 stated she was going to work with the kitchen to help straighten out some of the problems that they had going on with residents not receiving all the supplements that are ordered for them and making sure all residents get their meals. 3. R36's Transfer/Discharge Report documents an admission date of 10/04/19 with diagnoses including: Schizoaffective Disorder, Dementia, and Major Depressive Disorder. R36's Minimum Data Set (MDS) dated [DATE] documents no Brief Interview for Mental Status (BIMS) was performed due to resident is rarely/never understood. Section GG documented for R36's eating ability, substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) is needed. R36's Order summary report documents and order dated 03/30/2022 with no end date listed for: General diet - mechanical soft texture. Thin consistency, plate guard with pureed vegetable, extra gravy, fortified foods and ice cream with afternoon and evening meals. Another order dated 01/17/23 with no end date listed documents an order for health shakes two times a day in between meals at 7:00 AM and 3:00 PM. R36's Care Plan documents a Focus Area that R36 is unable to consume regular consistency foods and requires a mechanically altered diet with fruit and vegetables pureed. R36 has cognitive impairment and difficulty swallowing/chewing with a date of 04/25/21. The interventions documented are: monitor and record intake every shift, monitor for signs/symptoms of aspiration with a date of 09/07/2020, monitor weight as indicated monthly and PRN (as needed) with a date of 09/07/2020, position for eating and drinking safely with a date of 09/07/2020, provide diet as ordered, mechanical soft with pureed fruits and vegetables, fortified foods, extra desserts, heath shakes, 1 time daily with meals or as desired, whole milk at all meals. Plate guard provided to encourage self feeding with a date of 05/14/2021. Provide medications for hyperlipidemia and monitor for side effects and adverse reactions and report to MD if noted, with a date of 04/25/2021. Refer to ST (Speech Therapy) for evaluation and treat as indicated with a date of 09/07/2020. On 05/20/24 at 11:00 AM, V22 (Cook) made mashed potatoes with creamy classic mashed potatoes and hot water. No fortified potatoes were observed to be prepared. The recipe titled power potatoes documents ingredients: milk 2%, milk nonfat dry, potato, mashed instant, sour cream, margarine, and salt. On 05/20/24 at approximately 12:00 PM during lunch service, there was only one pan of mashed potatoes on the steamtable. Regardless if dietary cards listed fortified potatoes, the creamy classic mashed potatoes were observed to be served to all residents. On 05/20/24 at approximately 12:45 PM, R36 received a #10 dip of regular mashed potatoes, no fortified mashed potatoes, no extra gravy and no ice cream on his lunch tray. On 05/20/24 at 2:00 PM, V22 (Cook) stated that the mashed potatoes that were made for lunch were made with the potato flakes and hot water, and they were the only potatoes made and served that day. On 05/20/24 at 2:40 PM V28 (Activity Aide/CNA) passed afternoon snacks and there were no nutritional house supplements/shakes or ice cream on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/20/24 between 2:20 PM and 3:30 PM, R36 did not receive a health shake and no ice cream was given during snack time either. On 05/21/24 at approximately 12:40 PM, R36 received ground philly chicken sandwich, soft tater tots, and soft chopped fruit salad, R36 did not receive a nutritional house supplement, a fortified food item or ice cream with his lunch tray. On 05/21/24 at 2:30 PM, V28 passed afternoon snacks and there were no nutritional house supplements on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/21/24 between 2:35 PM - 3:15 PM, R36 did not receive a nutritional house supplement or ice cream during snack time. On 05/22/24 at 1:00 PM, R36 did not receive a nutritional house supplement, a fortified food item or ice cream with his lunch tray. On 05/22/24 at 2:35 PM, V28 passed afternoon snacks and there were no nutritional house supplements/shakes on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/22//24 between 2:35 PM - 3:15 PM, R36 did not receive a nutritional house supplement or ice cream. 4. R44's Transfer/Discharge Report documents an admission date of 08/03/20 with diagnoses including: Alzheimers's Disease with early onset, Disorientation, Essential Hypertension, Hypothyroidism, Unspecified Psychosis not due to a substance or known physiological condition, Dehydration, Fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, Seizures, and Rhabdomyolysis. R44's MDS dated [DATE] documents no BIMS was conducted due to R44 is rarely/never understood. Section GG indicates R44 is dependent for eating. R44's Physician Order Sheet documents an order for house nutrition supplement two times a day for nutritional supplement iso source 1.5 give 90cc (cubic centimeters) BID (twice a day) with an order date of 04/18/2024. R44's dietary card documents: lunch- nutritional ice cream in a bowl, power pudding, health shake for all meals. R44's Care Plan documents a Focus Area of R44 is unable to consume regular consistency foods with toast or breads all meals. R44 needs total assistance with all her meals with a revision date of 06/13/23 with interventions documented as: monitor and record intake every shift with a date of 11/06/20, monitor for sign/symptoms of aspiration dated 11/06/20, monitor weight as indicated weekly and prn dated 12/16/20, provide diet as ordered, mechanical soft with breads or toast with all meals, adding nutritional ice cream one time daily with meal of choice, health shake three times a day with meals, diet supplemented with 120 mls (milliliters) med pass TID (three times a day) dated 06/13/23, and refer to ST for evaluation and treat as indicated dated 11/06/20. On 05/20/24 at 12:40 PM, R44 did not receive nutritional ice cream in a bowl, power pudding, or a health shake. On 05/21/24 at 12:40 PM, R44 did not receive nutritional ice cream in a bowl, power pudding, or a health shake. On 05/22/24 at 1:00 PM, R50 did not receive nutritional ice cream in a bowl, power pudding, or a health shake.

Based on observation, interview, and record review, the facility failed to implement planned fall interventions to prevent falls for 1 (R1) of 5 residents reviewed for falls in a sample of 5. This failure resulted in R1 falling, fracturing his right hip and undergoing surgical repair of the fractured hip on 4/2/2024. This past non-compliance occurred from 3/31/2024 to 4/1/2024. Findings included: Per R1's EHR (electronic health record) R1 was admitted to this facility on 11/7/2024 with diagnoses of Alzheimer's, Chronic Atrial Fibrillation, Weakness and Insomnia. Per R1's MDS (Minimum Data Set) dated 1/23/24 under section C, R1 was assessed with a BIMS (Brief Interview for Mental Status) in which R1 scored 3 out of 15 total, indicating R1 has severe cognitive impairment. This same MDS under section GG, documents R1 as needing substantial/maximum assistance from staff for all transferring activities and uses a wheelchair for locomotion about the facility. A Fall Risk Assessment for R1, dated 4/1/2024, documents R1 is a high risk for falls. R1's care plan (initiation date of 11/30/23) documents a focus area of: (R1) is at risk for falls related to decreased safety awareness, unsteady gait and medications that may cause dizziness. This same care plan documents the goal of the focus area as: (R1) will not sustain serious injury through the review date (7/15/24) and planned interventions of: Ensure (bedside) recliner is in down position with foot rest down (initiation date 1/4/24), Anticipate and meet (R1's) needs (initiation date 3/10/24), Bed height to be placed where my feet are flat on the floor (initiation date 11/30/23), Educate (R1)/family/caregivers about safety reminders and what to do if (R1) falls (initiation date 11/30/23), Encourage (R1) to participate in activities that promote exercise, physical activity for strengthening and improved mobility (initiation date 11/30/23), Ensure call light is within reach (initiation date 11/30/23), Follow fall protocol (initiation date 3/10/24), Staff to assist (R1) with toileting upon awakening, before and after meals and at bedtime as (R1) allows (initiation date 4/2/24), and (R1) uses chair/bed electric alarm. Ensure the device is in place as needed (initiation date 11/30/23). On 4/4/2024 at 9:23am, V5 (family) said due to R1's dementia, R1 has increased confusion during the night and attempts to get up without assistance. V5 said the facility implemented a chair/bed pad alarming device to alert staff when R1 attempts to get up without assistance. V5 said she had not seen R1's chair/bed alarm recently when she visited R1 about a week before R1's fall. On 4/4/2024 at 12:30pm, V13 (Registered Nurse/ RN) said R1 uses a chair/bed pad alarm as a safety precaution to help prevent him from getting up and falling. V13 said she has performed safety rounds on R1's hallway and has seen R1's chair/bed pad alarm in his bedside recliner in the past. V13 was asked to point out where R1's chair/bed pad alarm was at, since the alarm pad could not be located in R1's room at the time of this interview. After searching, V13 responded she could not find the alarm. On 4/9/2024 at 8:45am, V20 (RN) was asked if she could locate R1's chair/bed pad alarm since a search of R1's room could not locate the alarm at the time of this interview. After searching, V20 said she could not find the alarm. On 4/4/2024 at 12:40pm, V6, V14, V15 (all Certified Nursing Assistants/CNA) said they are the usual day time staff who provide care for R1 and R1 is supposed to have a chair/bed pad alarm on. On 4/4/2024 at 2:40pm, V7 (CNA) said she, V8 (CNA) and V4 (RN) were the staff providing care for R1 on 3/31/2024 at the time R1 fell. V7 said R1 likes to sleep in his bedside recliner and does not really sleep in his bed. V7 said R1 does not use a chair/bed pad alarm and only uses a call light when R1 needs assistance. V7 said R1 did not have a chair/bed alarm on when he got up and fell the morning of 3/31/2024. On 4/4/2024 at 2:45pm, V8 (CNA) said she was working with V7 and V4 on 3/31/2024 when R1 fell. V8 said R1 did not have a chair/bed alarm on when he fell. On 4/9/2024 at 8:30am, V4 (RN) said on 3/31/2024, she was working with V7 and V8. V4 said at about 5:00am, she was passing medications when she heard R1 call out for help. V4 said she saw R1 on the floor in the hallway near R1's doorway. V4 said R1 told her he was looking for the bathroom when he fell. V4 said she assessed R1, determined he had a right hip injury due to complaints of pain and sent him to the local hospital ER (Emergency Room) for evaluation. V4 said R1 did not have on a chair/bed pad alarm on 3/31/2024 when he fell. A facility document titled Post Fall Investigation, dated 4/1/2024 documents R1 had an unwitnessed fall due to loss of balance when ambulating without staff, had on non-skid socks, and stated to staff at the time of his fall I was just trying to go to the bathroom. This same document has a place to mark if R1's chair/bed pad alarm was present and if the alarm was sounding at the time of the fall, however this section is left blank and nothing is marked. On 4/4/2024 at 9:23am, V5 (family) said she received a phone call from V4 (Registered Nurse/RN) on 3/31/2024 at around 6:00am informing her R1 had fell, was complaining of right hip pain and was being sent to the local hospital ER for evaluation. V5 said the ER told her R1 had a fractured right hip and needed surgery to repair the fracture. Th local hospital ER records dated 3/31/2024 documented R1 was seen for complaints of right hip pain after falling at his nursing home. A CT (Computed Tomography) scan and X-ray of R1's right hip documented R1 had a displaced intertrochanteric fracture of right femur and R1 was admitted for surgical management. These same hospital records included a document titled (local hospital) Report of Operation which documented on 4/2/2024, R1 underwent a surgical procedure of Right hip closed reduction with cephalomedullary nail to treat R1's right hip fracture. The facility Fall Prevention Policy dated 11/28/2012, documents the following in part: Purpose: To assure the safety of all residents in the facility. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions, to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. All assigned nursing personnel are responsible for ensuring on-going precautions are put in place and consistently maintained. Fall risk interventions will be identified on the care plan. On 4/9/2024 at 4:00pm, V1 (Administrator) pointed out R1's chair/bed alarm pad located in R1's room. A facility form titled In-service Sign in Sheet (dated 4/1/2024) documented all staff were in-serviced on the topic of: Fall Prevention and included a specific section related to R1's planned fall interventions. On 4/9/2024, V1 provided a document titled Past Non-Compliance Removal Time for outlining the actions taken by the facility prior to the survey date to correct the non-compliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: A Quality Assurance Performance Improvement Meeting was held on 4/1/2024 in which V1, V2 (Director of Nursing), V23 (Medical Director), V13 (RN), V24 (Activity Director), V25 (Assistant Director of Nursing), V26 (Care Plan Coordinator) and V27 (Social Service Director) were in attendance and identified the facility was not in compliance with specific regulatory requirements at the time the situation occurred. Actions Taken: 1.) Affected resident (R1) has been assessed, sent to the ER for treatment and assessed. (completed on 4/1/2024) 2.) All nursing staff have been educated on fall interventions. (completed on 4/1/2024) 3.) Affected resident's (R1) care plan updated. (completed 4/1/2024) 4.) Affected resident's (R1) family has been notified of fall (completed on 4/1/2024) 5.) All staff have been educated on fall intervention binders at nurses station (completed on 4/1/2024) 6.) A QAPI (Quality Assurance Performance Improvement) meeting was held with the medical director to discuss alleged allegation and facility comprehensive follow up (completed on 4/1/2024) 7.) The policy for fall prevention has been reviewed by the ID (interdisciplinary) Team with no changes needed at this time. (completed 4/1/2024)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer regularly scheduled ordered pain medication for 1 (R1) of 5 residents reviewed for pain management. This failure resulted in R1 experiencing loss of sleep and significant pain to R1's shoulders, back, and knees due to missing R1's 2/5/24 pm dose of her regularly scheduled pain medication. This past noncompliance occurred between 2/05/2024 - 2/09/2024. Findings: R1's face sheet documents an admission to the facility on 4/19/2023 with diagnoses of Chronic Kidney disease, Stage 3 Unspecified, Malignant neoplasm of uterus, part unspecified, other intervertebral disc degeneration, lumbar region, unspecified osteoarthritis, unspecified site, other sleep apnea. R1's Minimum Data Set (MDS) dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 13, indicating she is cognitively intact. R1's MDS Section J, Pain Management, documents she has a scheduled pain medication regimen. R1's Care Plan documents a Focus of: R1 has chronic pain; Goal: R1 will not have an interruption in normal activities due to pain through the review date; Interventions: Administer analgesia per orders; Evaluate the effectiveness of pain interventions; Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; Monitor/document for side effects of pain medication; Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. R1's Physician's Orders dated 4/20/2023 documents Pain Assessment every day and night shift; 4/19/2023 documents Acetaminophen 500mg (milligrams) (2 tabs) every 4 hours as needed for pain; 4/21/2023 documents Percocet 5/325mg three times a day for pain (Unspecified Osteoarthritis, Unspecified site; Other Intervertebral disc degeneration, lumbar region); 2/6/2024 documents Hydrocodone 5/325mg every 8 hours as needed for pain (may substitute if Percocet is unavailable). R1's Medication Administration Record (MAR) dated February 1 - 29, 2024 does not document Percocet 5/325mg was given on 2/5/2024 (9:00 PM); 2/6/2024 (5:00 AM, 1:00 PM, 9:00 PM) and 2/07/2024 (1:00 AM). R1's MAR dated February 1-29, 2024 documents pain assessment every day and night shift completed with pain rating on 2/5/2024 to be 6 and on 2/6/2024 to be 7. No alternative medication was ordered until 2/6/2024 and first dose was given at 5:37 PM. R1's Narcotic Administration Sheet for Percocet 5/325mg documents last dose given on 2/5/2024 at 1:00 PM and documentation of Percocet 5/325mg received on 2/7/2024 (30 tabs) with the next dose given on 2/7/2024 at 12:30 PM. R1's Progress Notes dated 2/06/2024, 6:00 PM (Late Entry) by V4 (Quality Assurance/Licensed Practical Nurse/LPN) documents in part .R1 came to this nurse and spoke about being out of her pain pills .asked R1 if she was having pain and R1 stated she was and had been to a doctor's appointment .told R1 a nurse sent a script to V20 (Primary Nurse Practitioner/NP), Monday (2/5/2024) to get signed .it came back Tuesday morning (2/6/2024) that it didn't have quantity amount or DEA (Drug Enforcement Administration) number on it .so V20 was going to escribe it to pharmacy .told R1 that hopefully it would come in on the delivery we would get Tuesday night .When pharmacy delivered Tuesday evening around 10:30 PM, did not have R1's pain medication. R1's Progress Notes dated 2/07/2024, 11:58 AM, documents in part .med delivery guy had been there and delivered R1's pain medications. On 2/14/2024, at 12:30 PM, R1 stated Last week either Sunday or Monday evening, the nurse came in and told me that I was out of my regular pain medication. R1 stated they told her a new nurse forgot to reorder it. R1 stated that the nurse told her that it probably wouldn't be here until tomorrow night and R1 stated that she was not offered any other type of pain medication until the following day. R1 stated that she has arthritis in her shoulders, back, and has had multiple knee replacements. R1 stated that she didn't get any sleep for three nights after missing her regularly scheduled pain medication and her pain was unbearable in her shoulders, back, and knees. R1 stated that she has been on scheduled Percocet for over twenty years and that is the only medication that helps to relieve her pain. On 2/14/2024, at 1:10 PM, V2 (Director of Nursing/DON) stated that R1's Percocet medication is not in the facility's emergency medication kit (E-Kit). V2 stated that it is the expectation of her nurses to have any medication that needs to be refilled, to be refilled in a timely manner before the medication runs out. V2 stated that it is the expectation of the nurses to call the primary physician when a medication runs out and get it refilled as soon as possible or get another order for an alternative medication to be given. V2 stated that R1 did get offered an alternative medication on 2/6/2024 and on 2/7/2024. On 2/14/2024, at 1:25 PM, V6 (Ombudsman) stated that V19 (Family) contacted her and told her that R1 ran out of her pain medication. V6 stated that she called R1 and R1 stated to her that she had not received her pain medication for 24 hours. V6 stated that R1 told her that she had been on regularly scheduled Percocet for over 20 years and that is the only pain medication that works for her. V6 stated that she offered R1 a grievance form to fill out. V6 stated that she spoke with V1 (Administrator) and was told R1 was offered an alternative medication but that she refused. V6 stated that V1 verified to her that R1's Percocet was not in the facility's emergency medication kit. V6 stated that V1 verified to her that R1 had missed 5-6 doses of her Percocet medication. V6 stated that V1 told her that R1's Percocet did arrive on 2/7/2024 and that the facility is monitoring to make sure this doesn't happen again. On 2/14/2024, at 1:40 PM, V1 (Administrator) stated that he spoke with V6 (Ombudsman) and told her that R1 ran out of her pain medication and that a back-up alternative was offered and given. V1 stated that R1's Percocet was ordered on 2/5/24 & 2/6/24 and received on 2/7/2024. On 2/14/2024 at 2:00 PM, the emergency medication kit was observed to have no Percocet available. There was hydrocodone 5/325mg available in the emergency medication kit. On 2/14/2024 at 3:05 PM, V9 (Registered Nurse/RN) stated that she works 6:00 AM - 6:00 PM regularly and she worked on 2/5/2024, day shift. V9 stated that she was told in report by V5 (RN) that R1 had one Percocet pill left and that it would need to be reordered. V9 stated that she called V20 (Primary Nurse Practitioner) and told her that we needed a new script for R1's Percocet medication. V9 stated that she gave R1 her last dose of Percocet at 1:00 PM on 2/5/2024. V9 stated that she told V5 (RN) in report that R1's Percocet medication was supposed to come in that evening. On 2/14/2024 at 3:10 PM, V5 (RN) stated that she worked Sunday night, 2/4/2024, and noticed that R1 only had one dose of Percocet left after she gave R1 her regularly scheduled 5:00 AM dose. V5 stated that she did not notify the primary physician at that time, just told V9 (RN) that R1 only had one dose of Percocet left and it needed to be reordered. On 2/20/2024 at 8:10 AM, V10 (RN) stated that she worked on 2/6/2024 and R1 was out of her Percocet medication. V10 stated that she called V20 (Primary Nurse Practitioner) and got an alternative medication (Hydrocodone 5/325mg) ordered for her until the Percocet would come in from the pharmacy. V10 stated that she offered Tylenol to R1 but R1 refused stating, That will not work for me and V10 stated she offered the hydrocodone to her and R1 refused the first time, stating, Those will not work for me, I threw 120 tablets away because that medication would not work for me. V10 stated that she talked to R1 and explained to her that hydrocodone was equivalent to Percocet and R1 finally agreed to take a dose of it. V10 stated that R1 was experiencing more pain than usual that day. V10 stated that R1's Percocet was supposed to arrive from pharmacy later that evening. On 2/20/2024 at 8:20 AM, V11 (Licensed Practical Nurse/LPN) stated that she worked on 2/6/2024, the night shift and was told in report that R1 was out of her Percocet medication and that hydrocodone could be given as needed until her Percocet medication could be delivered from pharmacy. V11 stated that R1's Percocet medication was supposed to arrive to the facility on 2/6/2024 but did not show up that evening. V11 stated that she called the pharmacy and they told her that it would arrive on the next pharmacy delivery, which would be in the morning. V11 stated that she administered the hydrocodone as ordered for R1 when she was able to have it. On 2/20/2024, at 8:40 AM, V20 (Primary Nurse Practitioner) stated that she was notified on 2/5/2024 that R1 needed her Percocet re-ordered. V20 stated that she reordered R1's Percocet that day but it was sent to the wrong pharmacy. V20 stated that she received another phone call on 2/6/2024 regarding R1 needing her Percocet reordered. V20 stated that when she went into the computer to order it again on 2/6/2024, she noticed she had sent the initial Percocet order to the wrong pharmacy. V20 stated that she reordered the Percocet again as well as ordered an alternative pain medication, hydrocodone 5/325mg that could be given as needed until the Percocet became available. V20 stated that it is her expectation for the nurses to notify her in a timely manner to refill medications and not wait until residents run out of medications. The facility's Pain Management policy dated 7/6/2018 documents in part .Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. The facility's concern/compliment form dated 2/7/2024 documents being filled out by R1 stating: I have to have my pain med regularly; I got my evening med and the nurse told me we were out of percocet and she would check to see if they were ordered; I didn't get my pain med until 2/7/2024 at noon; A very painful 2 days and nights. On 2/15/2024, at 10:30 AM, V1 (Administrator) stated that the facility had a Quality Assurance (QA) meeting on 2/9/2024 to discuss narcotic medications and medication refills. V1 stated the following people attended the QA meeting: V1 (Administrator), V2 (Director of Nursing), V4 (Quality Assurance/LPN), V16 (LPN/MDS/Care Plan Coordinator). V1 stated the measure put in place to ensure that deficient practice does not recur are: V2 (DON) and V4 (QA/LPN) will be checking narcotic books weekly (Tuesday) to see if the facility needs to get any scripts for narcotic medication refills to ensure that they don't run out of any narcotic medications. On 2/14/2024, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 2/09/2024. In attendance - V1, V2, V4, and V16. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents who receive narcotic medication have the potential to be impacted. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V2 and V4 provided in-service training on 2/9/2024 to nursing staff, (narcotic medications and medications refill). 4. Plan to monitor performance to ensure solutions are sustained: Narcotic medication audits to be conducted weekly x 4 weeks by V2 & V4. The first complete facility audit was completed on 2/13/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete weekly skin assessments, implement interventions to reduce pressure, and complete readmission assessments to identify any skin changes for 1 of 3 residents (R1) reviewed for being at risk for pressure injury in the sample of 3. This failure resulted in R1 developing pressure wounds. Findings include: 1. R1's face sheet documented an admission date of 6/15/23 and diagnoses including: chronic kidney disease, hypertension, dementia, hyperkalemia. R1's 9/15/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. R1's 9/15/23 MDS documented R1 required extensive two person assist with bed mobility, transfer, locomotion, dressing, and personal hygiene. R1's 7/3/23 Braden Observation documented a score of 18, indicating R1 was at risk for pressure wounds. R1's 9/15/23 Skin & Wound Evaluation documented a deep tissue injury related to pressure that was in-house acquired on the right lateral forefoot measuring 5.2 centimeters (cm) x 3.5 cm, a deep tissue injury related to pressure that was present on admission to the rear right malleolus (heel of the foot) measuring 5.6 cm x 4.7 cm, and a deep tissue injury related to pressure that was present on admission on the rear left malleolus measuring 5.64 cm x 4.21 cm. R1's Electronic Medical Record (EMR) documented R1 was transferred to the hospital on 9/10/23 and returned from the hospital on 9/14/23 at 7:40 PM. A progress note dated 9/14/23 at 7:40 PM documents that R1 returned to the facility with a new order for a daily dressing to the left heel. There was no readmission assessment documenting any skin conditions or wounds to R1's left heel. On 9/19/23 at 10:21 AM, R1 was lying in bed watching television. R1's bilateral heels were wrapped in kerlix dated 9/19/23. R1 was not interviewable and refused to have bandages removed. On 9/19/23 at 12:52 PM, V2 (Director of Nursing/ DON) said on 9/15/23 she went into R1's room to administer Intravenous antibiotics and while repositioning R1 noticed the wounds on R1's bilateral heels and side of the right foot. V2 said R1 had returned from the hospital on 9/14/23 and may have had the pressure wounds on admission but no readmission assessment was completed to document any skin conditions. V2 said all residents should have a skin assessment on admission or readmission. On 9/19/23 at 12:30 PM, V4 (Certified Nursing Assistant/ CNA) said R1 had large blisters on R1's bilateral heels 3-4 days or maybe a week prior to 9/10/23 when R1 was transferred to the hospital. V4 said she did report the blisters to the nurse but was unsure of who the nurse was or on what day she reported it. On 9/20/23 at 11:32 AM, V9 (CNA) said she noticed R1's bilateral heels to be black prior to 9/10/23 and reported it to 2 or 3 nurses but was unsure who. V9 said she was working on 9/14/23 when R1 returned to the facility from the hospital. V9 said R1's bilateral heels were black and looked really bad. V9 said she reported R1's skin changes to V8 (RN) on 9/14/23. On 9/20/23 at 11:27 AM, V8 (RN) said she did not recall R1. V8 said she did not work on R1's unit often and did not know the resident's names. V8 said she no longer was employed at the facility. On 9/20/23 at 11:38 AM, V10 (CNA) said she noticed one of R1's heels to black and nasty looking prior to 9/10/23. V10 said she had reported it to the nurse and thought the nurse was V6 (LPN). On 9/19/23 at 10:31 AM, V6 (LPN) said he was not aware of R1 having any pressure wounds prior to R1's 9/10/23 hospitalization. On 9/19/23 at 11:52 PM, V5 (Wound Nurse/ Registered Nurse/ RN) said she worked in the facility one day a week and would complete the wound documentation and take pictures of resident wounds. V5 said she had assessed R1's pressure wounds earlier in the day on 9/19/23. V5 said R1's right lateral foot pressure wound was closed and was a dark purple color measuring 5.59 cm x 3.83 cm, R1's right heel malleolus pressure wound measured 7.04 cm x 4.9 cm with 75% eschar and 25% of the wound bed being pink open tissue, and R1's left heel malleolus pressure wound measured 5.52 cm x 3.31 cm with 75% eschar and 25% of the wound bed being pink open tissue. V5 provided the pictures of R1's wounds on the wound treatment cell phone. R1's EMR documented a 9/15/23 care plan I have a pressure ulcer r/t (related to) disease process no previous care plan for pressure was documented. On 9/19/23 at 1:43 PM, V3 (Care Plan and MDS Coordinator/ LPN) said R1 had a Braden score of 18 indicating R1 was at risk for a pressure wound and should have had a care plan in place for being at risk for impaired skin integrity. V3 said he was unsure why R1 did not have a care plan in place prior to developing pressure wounds. V3 said he must have overlooked R1's need for a care plan for pressure to be implemented. On 9/19/23 at 12:52 PM, V2 (Director of Nursing) said any resident with a Braden score documenting a resident is at risk for a pressure wound should have a care plan with interventions to off load pressure. On 9/19/23 at 11:52 AM, V5 (Wound Nurse/ RN) said interventions for off-loading pressure would be found in a resident's care plan. V5 said she would expect any resident who was at risk for pressure wounds to have a care plan with interventions such as repositioning every 2 hours, floating a resident's heels while in bed, and wedges or pillows for positioning. On 9/19/23 at 10:31 AM, V6 (Licensed Practical Nurse/ LPN) said he was unsure what interventions R1 had in place to off-load pressure. V6 said for off-loading pressure all residents should be assisted to reposition every 2 hours. R1's EMR documented R1 requiring weekly skin assessments. R1's EMR documented a Weekly Skin Observation on 6/22/23, 6/29/23, 7/6/23, 7/13/23, 8/4/23 (23 days later), 8/11/23, 8/18/23, 9/1/23 (14 days later). The last documented skin assessment completed before R1's hospital admission on [DATE] was dated 9/1/23. The 9/1/23 weekly skin assessment documents that R1 had a blister to the left sole, ball of the foot that is blistered and scabbed over. R1's 9/1/23 assessment further documents no for the question Are any of these foot concerns new? There is no other documentation in the progress notes or physician's orders regarding a wound, or treatment to the wound, on the left heel prior to R1's 9/1/23 assessment. On 9/19/23 at 12:52 PM, V2 (DON) said the Weekly Skin Observations were automatically generated in the EMR and was unsure why they were not completed on R1. V2 said the Weekly Skin Observations were completed to assure new skin changes would be identified, documented, and treated. On 9/20/23 at 4:37 PM V11 (Physician) said if the facility had interventions in place to off-load pressure R1's pressure wounds could have been avoidable. The facility's 6/8/18 Skin Condition Assessment & Monitoring - Pressure and Non- Pressure policy documented . A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/ readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. Residents identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure and/ or other non- pressure skin conditions are identified by a licensed nurse . The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure call lights were answered timely for 6 of 6 (R5, R6, R7, R8, and R9, R20) residents reviewed for resident rights in the sample of 20. This failure resulted in the following 1. R5, who had a history of a brain bleed, was laying on the floor for four hours before being found by facility staff. 2. R9 who has a history of pressure ulcers and is being up in his chair for more than two hours, sitting in urine that burns his skin, and being in pain. 3. R6 who had recently had a catheter removed does not get timely bladder training and has to do bladder training herself in her adult incontinent brief since it took facility staff too long to respond to the call light. This has the potential to affect all 67 residents residing in the facility. Findings Include: 1. R5's facility admission Record with a print date of 10/20/2022 documents R5 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, cardiac arrythmia, dependence on renal dialysis, type 2 diabetes, morbid obesity, atrial fibrillation, and person injured in unspecified vehicle accident. R5's MDS (Minimum Data Set) dated 10/08/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R5 is cognitively intact. Section G of R5's MDS documents R5 requires two-person physical assist for transfers and one-person physical assist for bed mobility. R5's undated care plan documents a Focus area date initiated 10/08/22 of I am at (Specify High, Moderate, Low) risk for falls r/t (related to). Goal: I will not sustain serious injury through the review date. Date initiated: 10/08/2022, Target Date: 01/06/2023, Interventions/Tasks: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt responses to all requests for assistance. Date initiated 10/08/2022. R5's progress notes document on 10/12/2022 7:30 AM that R5 had an un-witnessed fall at 6:30 AM in his room when he attempted to arise from his recliner to take himself to bed. The note documents that R5 slid from his recliner to the floor, stated no injuries were obtained. The progress note also documents R5 was alert and oriented to time, person, place, and situation. No injuries observed. The note further documents the following intervention: re-educate resident frequently to use call light, assure call light and cell phone is within reach at all times. The facility Concern/Compliment Form dated 10/13/2022 documents under Nature of Concern/Compliment, R5 stated that he slid out of his recliner into the floor. Resident (R5) stated he doesn't know what happened or how long he had been there. Stated he has moments where he forgets. Under Summary of Pertinent Findings, the report documents, After investigating incident, resident was found to be in floor for only a short amount of time. No injuries noted. Under Corrective Actions Taken: Staff educated on timely call light monitoring. On 10/18/22 at 4:00 PM, V5 (Family Member) stated she was informed by a family member that R5 had reported to them he ended up in the floor around 2:00 AM and that R5 had pushed the call light multiple times and hollered for help, but no one came until around 6:30 AM to assist him. R5's local hospital emergency room record dated 10/12/22 documents R5 was evaluated at the local hospital at 2:33 PM for a fall. Under Assessment R5's hospital Nurse's Notes documents, Patient brought to ER (emergency room) from (name of facility) by family member who reports patient fell at nursing home this morning. Patient was in floor for approx. (approximately) 4 hrs (hours) and is unsure if he slid off the bed or had stood up and fell. Patient is slightly confused and family states that patient has been declining cognitively since Sunday. On 10/19/22 at 9:32 AM, R5 was alert and oriented and asked about his fall on 10/12/22. R5 stated he was sitting in his chair in his room and must have dozed off. R5 stated when he woke up, he had slid down the front of his chair and couldn't get back up. R5 stated he tried to find the call light but couldn't find it at first. R5 stated he hollered out several times. R5 stated he then found the call light and pushed it around 2:00 AM. R5 stated the facility staff finally came in after 6:00 AM and got him up and took him to the bathroom. R5 stated he pulled the chain in the bathroom, and no one came back. R5 stated he would tell staff he needed something, and they wouldn't come back. When asked how he knew how long he was laying in the floor the morning of his fall, R5 stated because he could see the clock on the wall. R5 stated at some point he ended up with his head on the floor under the table next to his bed in his room. On 10/27/22 at 10:39 AM, surveyor observed the room where R5 resided while at the facility. The beds in the room were facing a wall with a clock in the center of that wall. A recliner was beside one of the beds also facing the wall with the clock. The clock was noted to have accurate time displayed. On 10/18/22 at 12:58 PM, V6 (CNA/Certified Nursing Assistant) stated R5's call light was on when she came to work on 10/12/22 at 6:00 AM. V6 stated V8 (CNA) went into R5's room and found R5 on the floor. V6 stated she didn't provide care to R5 that day. On 10/18/22 at 3:00 PM, V8 (CNA) stated R5's call light was on when she got to work on 10/12/22. V8 stated she answered a different residents call light first and provided care to that person then went to R5's room. V8 stated when she entered R5's room she saw him on the floor in front of his recliner with his head in front of his recliner. V8 stated R5 appeared to have missed his chair when sitting down. V8 stated she immediately went to get the nurse to assess R5. V8 stated R5 reported to them he had been laying there for hours and had been calling for help. On 10/21/22 at 12:02 PM, V20 (LPN/Licensed Practical Nurse) stated she was working on 10/12/22 when R5 fell. V20 stated the CNA told her he had fallen. V20 stated it was after she had given report to the oncoming day shift. V20 stated it appeared as if R5 had fallen out of his recliner. V20 stated she couldn't remember if R5's call light was on at that time, but she knew it wasn't on when she was on that hall around 4:30 or 5:00 AM. V20 stated she was pretty sure R5 had received medications on the morning of 10/12/22. V20 stated she wasn't sure, but she knew she was in the room next to R5's that morning and had a conversation with the CNA's in the hallway right outside R5's room. R5's Medication Administration Record (MAR) dated 10/1/22 to 10/31/22 has no documentation showing any medications were administered on the morning of 10/12/22. On 10/26/22 at 10:30 PM, V21 (CNA) stated she took care of R5 on the night of 10/11/22 into the morning of 10/12/22. V21 stated she couldn't remember if R5 used his call light on the night of 10/11/22 or the morning of 10/12/22. V21 stated she couldn't remember when exactly they were in R5's room that night but she checks on every resident every couple of hours. On 10/26/22 at 10:24 PM and 10:40 PM, V22 (CNA) stated she provided care to R5 on 10/11/22 into the morning of 10/12/22. V22 stated she was in R5's room around 8:30 PM or 9:00 PM and then again at 2:00 AM and 4:00 AM. V22 stated she didn't remember if R5's call light was on at any time through the night. V22 stated it takes approximately 3 minutes to answer the lights and she hasn't had any residents complain call lights aren't being answered timely. When asked if she was involved with R5's care when he fell on the morning of 10/12/22, V22 stated she was probably giving report. When asked how they give report, V22 stated they do rounds. When asked to explain what that means, V22 stated they go to each room and tell the oncoming shift what happened with the resident through the night. When asked if she remembered doing rounds on the morning of 10/12/22, V22 stated they try to do them every morning. When asked if she saw R5 when she was doing rounds on the morning of 10/12/22, V22 stated, No, he was probably already up. On 10/27/22 at 10:52 AM, V6 (CNA) stated she got report at the nurse's station on the morning of 10/12/22. When asked if they did rounds and saw each resident, V6 stated they did not. When asked if anyone reported R5 falling V6 stated, No. On 10/26/22 at 9:41 AM, V1 (Administrator) stated R5 couldn't have been in the floor from 2AM to 6AM like R5 said. V1 stated he knew R5 didn't have his call light on because R5 said it was in his hand and then he said it slid out of his hand and the video shows people walking up and down the hallway. When this surveyor asked to view the video, V1 asked if it would help his case. This surveyor stated she was unsure due to not having seen the video yet. On 10/27/22 at 2:15 PM, this surveyor observed the video of R5's hall on 10/12/22 with V1 and V2 (DON/Director of Nurses) present. The door to R5's room was not clearly visible as the camera was facing the opposite wall and there was something obstructing the direct view of R5's doorway. At 5:48 AM, there was a CNA (possibly V21) who entered the hallway and got linens off the cart in the hallway. V21 then entered either R5's room or the room next to it. V21 then exited the room with dirty linens and placed them in a receptacle. On this same date and time, V2 stated R5 had been incontinent. R5's nurses notes reviewed from 10/07/22 to 10/13/22 document R5 is continent of bowel and bladder. V1 (Administrator) walked down the hall on live video to show this surveyor V21 entered R5's room. It was not clear on the live camera feed, which room V1 was entering. Based on the view available from the video, it was not possible to determine if V21 entered R5's room or the room next to it. 2. R9's facility admission Record with a print date of 10/26/22 documents R9 was admitted to the facility on [DATE] with diagnoses that include unspecified wound left foot, paraplegia, osteomyelitis, hypertension, and insomnia. R9's MDS dated [DATE] documents a BIMS score of 13, which indicates R9 is cognitively intact. Under Section G of this same MDS, R9 is documented as requiring assist of two staff for transfers and toileting. R9's undated and incomplete care plan documents a Focus area of I have an ADL (activities of daily living) self-care performance deficit r/t (related to) Interventions included are, Bed Mobility: The resident requires (Specify what assistance) by (X) staff to turn and reposition in bed (specify frequency) and as necessary toilet use: The resident requires (Specify assistance) by (X) staff for toileting, transfer: The resident requires Mechanical Lift (specify) with (x) staff assistance for transfers. R9's care plan documents a Focus area of I have diabetic ulcer of the (specify location) r/t with interventions that include, Position resident off affected area. Change position every 2 hours and PRN (as needed). On 10/18/22 at 3:00 PM, V8 stated she has told R9 he could talk with V2 (DON) about call light complaints. V8 stated she left a note in V2's office addressed to the Director of Nurses and Administrator for R9. On 11/03/22 at 1:04 PM V2 (DON/Director of Nurses) stated she knew she had gotten notes and/or verbal updates related to R9, but she couldn't remember a specific note related to call lights. On 10/27/22 at 3:00 PM, R9 was observed sitting in his motorized wheelchair in the hallway. R9 entered his room and stated he had been waiting to go to bed for two hours. R9 stated staff come and turn his call light off and then he turns it back on. R9 stated his bottom hurts bad as well as his hips and his legs. R9 stated he has had to wait for them to change his depends and when the urine sits on his skin it burns, like it is right now. R9 stated he has been in his chair since 11:00 AM and he starts hurting about an hour after he gets up. R9 stated the pain just gets worse and worse. R9 stated it makes him angry when they do this and he has never been angry in his life, but they are making him that way when they don't answer the call lights and/or provide care. R9 stated, watch this. R9 pushed his call light at 3:03 PM. This surveyor did continuous observation from inside R9's room. At 3:25 PM this surveyor could hear staff talking in the hallway outside R9's room. Staff entered R9's room at 3:32 PM and R9 told them he wanted to go to bed. They left and returned with a mechanical lift at 3:38 PM. This indicates R9's call light was unanswered from 3:03 PM until 3:32 PM. On 11/10/2022 at 12:15 PM, R9 stated, he would like to report another late call light experience that just happened. R9 stated, today (11/10/22) at about 11:00 AM, he was in bed, turned on his call light wanting to get up, and an unidentified staff member came in the room and shut off his light. R9 stated, he waited and called the nurses station to have them get him up and was told they would send someone to his room. R9 stated, he did not know names of any of the staff because he did not ask and they do not wear name tags. R9 showed his phone to surveyor with a call to the facility at 11:39 AM. R9 stated, at about 12:00 PM he turned on his call light again and a CNA came in and got him up within about 5 minutes. R9 stated, he has reported call light issues to administration before and nothing has been done about it. R9 stated, his roommate (R7) also has issues with staff not answering his call light timely. 3. R6's facility admission Record with a print date of 10/20/22 documents R6 was admitted to the facility on [DATE] with diagnoses that include encounter for surgical after care, diabetes, morbid obesity, chronic kidney disease, mild cognitive impairment, hypertension, and necrotizing fasciitis. R6's MDS dated [DATE] documents a BIMS score of 12, which indicates R6 has a moderate cognitive impairment. Section G of R6's MDS documents that R6 requires assist of two staff for bed mobility, transfers, and toilet use. R6's undated care plan documents under the Focus area, I have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) obesity, DM II (type 2 diabetes), mild cognitive impairment with interventions that include R6 requires extensive assist by 2 staff for toileting and transfer. On 10/18/22 at 5:44 AM, R6's call light was observed on. R6 stated her call light had been on for about 20 minutes. R6 stated that is about the average time it takes for a call light to be answered. R6 stated she has waited for up to four hours before to get assistance to be lifted with the mechanical lift. R6 stated she recently had a catheter removed and has some urge incontinence. R6 stated the light situation is so frustrating. R6 stated staff will come to her room, turn the call light off, say they need to find someone to help them, then leave, and you never know when they will come back. R6's call light remained on throughout the interview with at least one unidentified staff member passing by her room during the interview. R6's call light was observed on and not answered until 6:16 AM. This indicates R6's call light was unanswered by staff for 32 minutes. On 10/18/22 at 3:00 PM, when asked if she had residents complain call lights weren't being answered timely V8 (CNA) stated, Absolutely. V8 stated R6 was very appreciative of the care V8 provided and had reported to V8 that R6 will have a need for something that requires two people such as a mechanical lift transfer and R6 reported it may be up to four hours before she gets assistance. V8 stated she told R6 she could talk with V2 (DON) about it and R6 declined on that day. On 10/25/22 at 10:12 AM, R6 was observed sitting in her recliner in her room with her family at her side. R6 stated she had to wait an hour yesterday (10/24/22) when she needed a mechanical lift to get up. On 10/27/22 at 3:55 PM, R6 was observed sitting in the recliner in her room. When asked if there was any negative impact when it took a while for staff to answer her call light R6 stated, It makes me feel like I don't matter. R6 stated she had a urinary catheter until recently and she is supposed to be doing bladder training since it has been removed. R6 stated it is really hard to train your bladder when it takes two and a ½ hours for them to answer the call light. R6 stated she has been bladder training herself in her incontinence brief. 4. R7's facility admission Record with a print date of 10/26/22 documents R7 was admitted to the facility on [DATE] with diagnoses that include acquired absence of left leg below the knee, lack of coordination, diabetes, Mild Intellectual Disabilities, chronic kidney disease, schizoaffective disorder, and hypertension. R7's MDS dated [DATE] documents a BIMS score of 11, which indicates R7 has a moderate cognitive impairment. Under Section G, the same MDS documents R7 requires assist of two staff for transfers and toileting. R7's undated Care Plan documents a Focus area of I have an ADL self-care performance deficit r/t Mild Intellectual disabilities and lack of coordination. Interventions documented on the care plan include, Toilet Use: R7 is dependent on mechanical and 2 staff with toileting at this time. Transfer: R7 is dependent on mechanical lift and 2 staff for transfers between areas as necessary. On 10/25/22 at 2:12 PM, R7 was observed sitting in his room. R7 stated the facility staff don't answer call lights timely. R7 pushed his call light at 2:13 PM. A CNA came into R7's room almost immediately and he told her he was wanting to get up. She stated she would have to get the mechanical lift after other staff were finished using it and would be right back. On 10/25/22 at 2:38 PM, this surveyor observed R7's call light back on. Upon entering the room R7 was observed still laying in bed. R7 stated staff haven't been back in to get him up. On 10/25/22 at 2:42 PM, R7 was observed still in bed, and he stated staff keep coming in and turning his call light off and saying they have to get help and will be right back. At 2:48 PM staff are observed entering R7's room with a mechanical lift. This indicates R7 waited 36 minutes for staff to assist him out of bed. 5. R8's facility admission Record with a print date of 10/20/2022 documents R8 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, hypertension, cognitive communication deficit, major depressive disorder, and abnormalities of gait and mobility. R8's MDS dated [DATE] documents a BIMS score of 14, which indicates R8 is cognitively intact. Section G of R8's MDS documents that R8 requires two-person physical assist for transfers and toileting. R8's undated care plan documents a Focus area I have an ADL self-care performance deficit r/t decreased mobility, lack of coordination with interventions that include R8 requires extensive assist by 2 staff for toileting and R8 requires a mechanical lift with two staff to move between surfaces. R8's care plan documents a Focus area of I am a non-reliable responder with interventions that include, Allow resident to voice perceptions thru active listening, ask open ended questions, investigate resident statements and/or concerns, praise factual statements, redirect with kindness, do not argue with resident. On 10/18/22 at 6:00 AM, 6:15 AM, and 6:21 AM R8's call light is observed on. On 10/18/22 at 6:21 AM, R8 was observed lying in bed. R8 stated the facility staff were supposed to have gotten her up at 5:00 AM. When asked why they were to get her up that early R8 stated Because I wanted to get up. R8 stated she put her light on at 5:00 AM and told the staff last night she wanted to get up at 5. When asked if it normally takes a while for them to answer call lights R8 stated, Oh my God, yes, sometimes 2-3 hours. When asked if anything negative had happened when it took staff awhile to answer her call light R8 stated, wet the bed, pooped the bed. On 10/18/22 at 6:45 AM, staff entered R8's room to assist her up. Aside from R8's verbal report of activating her call light at 5AM, R8's call light was visually seen by this surveyor as unanswered from 6:00 AM until 6:45 AM, indicating her call light was on for 45 minutes. On 10/18/22 at 12:58 PM, V6 (CNA) stated they usually have three CNA's, a shower aide, and a restorative aide on Daisy and two CNA's on Rose. When asked if this is enough staff to provide care for the residents, V6 stated she believed so. When asked why it took so long answer the call lights on the morning of 10/18/22, V6 stated she wasn't sure. V6 stated she wasn't at the facility the whole time. V6 stated she usually gets to the facility around 6:00 AM. V6 stated night shift didn't say anything about the light being on or how long it had been on. On 10/18/22 at 3:00 PM, when asked if 45 minutes was too long for a call light to not be answered, V8 (CNA) stated she thought a call light that was not answered for that long could be dangerous. 6. R20's facility admission Record with a print date of 11/3/22 documents R20 was admitted to the facility on [DATE] and discharged from the facility on 8/3/22. R20's diagnoses listed on the admission Record include Clostridium difficile, diarrhea, anxiety disorder, acute kidney failure, hypertension, cognitive communication deficit, hematuria, vertigo, urinary tract infection, and lack of coordination. R20's MDS dated [DATE] documents a BIMS score of 12, which indicates R20 has a moderate cognitive impairment. The same MDS Section G documents R20 requires assist of two staff for transfers and toileting. R20's facility care plan with a Focus area of I have an ADL self-care performance deficit r/t with interventions of Transfer: R20 requires limited assist by 1 staff at times to move between surfaces as necessary. PT/OT (physical therapy/occupational therapy) evaluation and treatment as per MD (physician) orders. The facility Concern/Compliment Form dated 7/6/22 documents under Nature of Concern/Compliment waited over an hour to be changed, yelling out for help. Resident (R20) say (sic) he wearing (sic) Put in bed and did not change, left me there, change clothes finally this morning. His bottom is red and hurts. On 10/19/22 at 12:55 PM, V10 (Social Services Director) stated R20 was discharged home. V10 stated she was the one who assisted him with his concern. V10 stated R12 had his call light on, and staff came down and put him to bed without changing him. V10 stated they didn't put his pajamas on and left R20 in his clothes. V10 stated R20 had Clostridium Difficile (C-diff) and would sometimes have accidents and he was supposed to get assistance to go to the bathroom. V10 stated R20 reported to her that he knew the staff hear residents hollering all day and night. V10 stated he was a little upset, but he just wanted the facility to know what happened. V10 stated she thought R20's bottom was red and hurting because of the C-diff not because he had been left all night without changing him. V10 stated R20 reported they would pass the call light up and he would yell out and the staff weren't responding to him. V10 stated R20 went an hour until someone came and answered his call light and took him to the bathroom, but he went all night in his clothes. The facility Resident Council meeting minutes documents the following, 5/11/22 Old business .Hard to get help in rooms during mealtimes. 6/8/22 Old Business .Hard to get help in rooms at meal times- Getting better. 7/13/22 .Nursing Call lights- Not answered on timely manner . 8/10/22 .Nursing: Call lights not getting answered timely. 9/14/22 .Nursing: .Call lights looked (sic) 10/12/22 .Nursing: Good- Still need work on call lights. Residents waiting long periods to be laid down. The facility Complaint Resolution Form dated 7/13/22 documents, Problem: Call lights- Not answered on a timely manner. Department: Nursing. Resolution: Call light education for staff on 7/25/22. The facility Complaint Resolution Form dated 8/10/22 documents, Problem: .Call light not answered timely manner .Resolution: call light response time will be monitored . There were no other Complaint Resolution Forms provided to this surveyor. On 10/19/22 at 12:55 PM, V10 (Social Services Director) stated she was responsible for reviewing and following up with some of the facility grievances/resident council meeting concerns. V10 stated they have had concerns with call lights not being answered timely brought up in resident council meetings. Reviewed with V10 the resident council meeting minutes that document concerns for the past four months. When asked what the facility has done to address the call light concerns V10 stated they had educated staff, including non-nursing staff that anyone can answer the call light. V10 stated if the person that answers the call light is not able to fulfill the need, they should pass it on to the nursing staff and then follow up with the resident in 15 minutes to ensure the need was met. V10 stated she also knows the facility did a questionnaire and an in-service, but she wasn't involved in implementing those. On 10/20/22 at 6:45 AM, when asked if she knew why call lights weren't being answered timely, V14 (LPN), stated if they put the call light on when supper trays go out or in the morning when people are getting up it may extend the time it takes to answer them. On 10/21/22 at 1:55 PM, when asked how quickly call lights should be answered V2 (DON) stated, In a timely fashion. V2 stated they have educated staff on answering call lights timely and are implementing nursing staff and CNA staff to come in at different times so they can monitor call lights better. V2 stated they did a call light audit, but she felt it would be more accurate if they had a different system. V2 stated she has also come to the facility at different times at night to audit call lights. On 10/26/22 at 9:41 AM, when asked when he became aware call lights weren't being answered timely and what the facility did about it, V1 stated, the majority of call lights happen all at the same time. V1 stated that is when everyone wants to lay down or get up. V1 stated he has tried to teach staff to prioritize call lights and they have done call light audits. V1 stated it usually takes them about 10 minutes on average to answer the lights. This surveyor informed V1 that call light observations revealed they weren't answered for 30-45 minutes on the morning of 10/18/22, and he stated that is when everyone wants to get up and the nursing staff are doing their rounds during that time frame. When asked if that was an appropriate time frame for call lights to be answered V1 stated he would like to see them answered sooner than that. This surveyor informed V1 that R8 stated she wanted to get up at 5:00 AM and V1 stated that was funny because R8 never wanted to get up early. When asked if he thought R8 really didn't want to get up early V1 stated, No. She (R8) is one who could lay in bed all day and never want to get up. When asked what his expectation would be in the situation where staff turn the call light off, leave, and don't come back, V1 stated he would expect them to go back and finish the task or leave the call light on until the need is met. Reviewed with V1 the observation on 10/25/22 of staff telling R7 they would have to wait for the mechanical lift and V1 stated, maybe the battery wasn't charged on the mechanical lift, or some staff don't like to use the manual lift, or one resident takes a lot longer to transfer. When asked if that was an acceptable time frame to wait to get up, V1 stated he would like it to be sooner, but it just depends on the circumstances. On 11/04/22 at 3:21 PM, V2 stated there is no specific time frame that call lights are to be answered in the facility call light policy. When asked how staff know what the expectations are regarding how quickly a call light should be answered, V2 stated, they should just be prioritized by what resident needs, need to be met first. The facility Call Light policy dated 11/28/12 documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident respond to call system and promptly cancel the call light when the room is entered. 3. Bathroom lights should be viewed as emergencies and immediate attention will be given. 4. Requests shall be responded to in a courteous and professional manner. 5. Hand bells will be provided for alert dependent residents when position out of reach of permanent call light when needed. 6. Call bell system defects will be reported promptly to the Maintenance Department. Check room frequently until system is repaired . The facility Daily Census dated 10/16/22 given to this surveyor on 10/18/22 documents 67 residents reside at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents were not restrained for staff convenience for 1 of 3 (R3) residents reviewed for restraints in the sample of 20. R3 who has a severe cognitive impairment, had a fall on night shift, was unsteady on his feet, and refusing to stay in bed. Facility staff placed R3's mattress on the floor and placed R3 on his mattress. R3 was unable to stand up from the floor and crawled on his hands and knees to the door and asked for help. A reasonable person would have felt humiliation, fear, had loss of dignity, anxiety, and agitation, as well feelings of being dehumanized by being placed in a position they were only able to crawl away from. Findings Include: R3's admission Record with a print date of 10/20/22 documents R3 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, dementia, hypothyroidism, dysphagia, brief psychotic disorder, chronic kidney disease, mood disorder, and schizoaffective disorder. R3's MDS (Minimum Data Set) dated 9/8/22 documents a BIMS (Brief Interview for Mental Status) score of 01, which indicates R3 has a severe cognitive impairment. R3's same MDS documents R3 requires assist of two staff for bed mobility and transfers. Under balance during transitions and walking, R3's MDS documents R3 is not steady, only able to stabilize with staff assistance. Under Functional Abilities R3's MDS documents, to go from lying to sitting on side of bed R3 requires partial/moderate assistance. R3's Restorative Observations dated 9/14/22 documents R3 is able to voluntarily move or reposition in bed and no restraints are in use. Under Care Plan it documents (R3) is able to turn side to side, go from lying to sitting and sitting to lying with supervision and verbal cues of staff at times. R3 is supervision for transfers and supervision for locomotion and mobility at times. R3's progress notes document, 9/9/22 6:25 PM Resident had a witnessed fall 09/09/2022 6:25 PM Location of fall: Residents room, Res (resident) found on floor in room and noted to have a small laceration to back of head, approx. (approximately) 3 cm. Resident assisted up and onto bed. Refuses to stay in bed, gait is unsteady and leaning backwards. Alert and disoriented per usual baseline. Assisted into bed but refuses to stay. Interventions: Mattress put on floor. R3's Fall IDT (Interdisciplinary Team) Note dated 9/12/22 10:10 AM documents, Resident observed laying on floor in room, noted to have hematoma and laceration approx. 3 cm to back of head. Moves all ext (extremities) without difficulty or c/o (complaints of). Hollering get me up. Denies any c/o (complaints of) of discomfort. Neuro (neurological) checks initiated and WNL (within normal limits). Assisted up x (times) 2 staff and amb (ambulated) to bed. Refuses to stay in bed. Ambulating per self, gait is unsteady, and resident is leaning backwards when walking. Root Cause of fall: Resident lost balance, ambulating without assistance. Intervention and care plan updated: Resident moved to room right across from nurse's station for increased monitoring. On 10/20/22 at 9:52 AM, V15 (LPN/Licensed Practical Nurse) stated, one-night (date unknown), R3 fell and bumped his head and she put his mattress on the floor that night. V15 stated R3 had a 2-3 cm laceration on the back of his head. V15 stated she did neuro (neurological) checks, fall monitoring, and behavior monitoring, called the physician, and gave R3 snacks. When asked how putting the mattress on the floor helped, V15 stated, Well he wasn't able to get up. V15 stated she was the only one on that unit and she wasn't able to properly supervise R3. V15 stated the CNA (Certified Nursing Assistant) working with her on that night got sick and left the facility around 2:00 AM. V15 stated she tried to call people in, but no one was able to. V15 stated it is not typical to only have one staff member working on the unit. On 10/20/22 at 12:46 PM, this surveyor informed V2 (DON/Director of Nurses), of V15's interview of putting R3's mattress on the floor and V15 stated R3 couldn't get up. V2 stated she would consider putting R3's mattress on the floor a restraint and R3 isn't assessed for needing restraints. A statement by V15 dated 10/20/22 that was provided to this surveyor by V1 (Administrator) and V2 (DON) documents, I spoke with the state surveyor concerning R3 the night he fell, I was alone on unit as the CNA scheduled was sick and left. R3 was restless, refusing to stay in bed. I told her he was restless, refusing to stay in bed. I also had told her I walked with him, gave him snacks and attempted to sit with him to calm him down. Ineffective. He was leaning backwards while walking and balance was very poor and put his mattress on floor for his safety r/t (related to) balance and restlessness and attempting other redirection without success. On 10/21/22 at 12:02 PM, V20 (RN/Registered Nurse) stated she had never seen R3's mattress on the floor. V20 stated R3 would be able to get up from the floor without assistance. V20 stated she had never seen R3 get up from the floor, but he got out of his bed that was in a low position without assistance. On 10/26/22 at 1:08 PM, V23 (MDS Coordinator/Certified Restorative Nurse) stated he does restorative assessments on the residents and last assessed R3 on 9/14/22. V23 stated he saw R3 walking in the hallways after that assessment and wasn't aware of a decline in his functional capabilities. V23 stated he believed R3 could get up off the floor. V23 stated he believed R3 would have to crawl to some type of support to get up but that he could get up, once he had the support of a bed, wall, or chair. On 10/21/22 at 1:55 PM, when asked why R3's mattress wasn't still on the floor V2 (DON) stated they probably moved it after that because they came up with a different intervention. V2 stated they probably changed it because it didn't work, and they didn't want R3 to trip over it. On 10/26/22 at 9:41 AM, V1 (Administrator) was asked about R3's mattress being put on the floor as an intervention. V1 stated (V15) ensured the safety of the resident, and he was good with the mattress being on the floor, if it was being used as a safety measure. V1 stated he thought increased monitoring would have ensured R3's safety, so his mattress wouldn't have to be put on the floor. On 11/01/22 at 4:20 PM, V15 (LPN) stated on 9/9/22 after she had moved R3's mattress to the floor R3 was able to get off the mattress and, did in fact get off it, while she was working that night. V15 stated R3 crawled on his hands and knees to the door of his room and asked for help. V15 stated she had to go to the other side to get another nurse to assist her in getting R3 off the floor. V15 stated she did not believe it would have been safe for her to assist R3 off the floor by herself. V15 stated she put R3 back in his bed and she believed he stayed there the remainder of the night. R3's undated Care Plan documents a Focus area of I am at High risk for falls r/t (related to) dementia, reduce safety awareness and wandering behaviors. Goal: All falls will be reviewed by the IDT (Interdisciplinary Team) through next review. Interventions documented on the care plan are as follows, 4/29/19- Be Sure R3's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage R3 to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: walking to meals and activities. Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. 5/2/2019- Staff educated to make sure all personal items including water glass on the bed side table are in reach when in bed. 12/17/19-Sign (tractor) to be put on R3's door to assist him while finding is (sic) room. 12/27/19- R3 needs activities that minimize the potential for falls while providing diversion and distraction. 3/4/20-Remove all tripping hazards from room at this time. 4/13/20- Staff to ensure that R3 has all items in reach when eating. 7/13/20-Encourage R3 is (sic) wearing appropriate footwear non-skid socks or shoes when ambulating as he allows. 12/15/21- Ensure rolling desk chair is securely pushed up under desk. Place stationary chair behind nurse's station. 9/12/22-R3 room relocated closer to nurse's station to increase monitoring. 10/19/22- Night light added to R3's room to decrease falls. 10/10/22-Staff to offer assistance when R3 is ambulating as he will allow. There is no restraint focus area documented on R3's undated care plan. The facility Abuse Prevention and Reporting - Illinois policy dated 11/28/16 documents, Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure falls were investigated, new and/or appropriate interventions to prevent falls were implemented, and appropriate levels of supervision were in place to prevent injury for 4 of 4 residents (R2, R3, R4, and R5) in the sample of 20 investigated for falls. This failure resulted in R3 having four falls from 9/9/22 to 10/19/22 that resulted in hematomas and lacerations to his head with neurological checks not completed per facility policy, multiple bruises and cuts, and a subsequent stay at a mental health facility for a medication evaluation and adjustment. Findings Include: 1.R3's admission Record with a print date of 10/20/22 documents R3 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, dementia, hypothyroidism, dysphagia, brief psychotic disorder, chronic kidney disease, mood disorder, and schizoaffective disorder. R3's MDS dated [DATE] documents a BIMS score of 01, which indicates R3 has a severe cognitive impairment. R3's same MDS documents R3 requires assist of two staff for bed mobility and transfers. Under balance during transitions and walking R3's MDS documents R3 is not steady, only able to stabilize with staff assistance. Under Functional Abilities R3's MDS documents to go from lying to sitting on side of bed R3 requires partial/moderate assistance. R3's Restorative Observations dated 9/14/22 documents R3 is able to voluntarily move or reposition in bed and no restraints are in use. Under Care Plan it documents (R3) is able to turn side to side, go from lying to sitting and sitting to lying with supervision and verbal cues of staff at times. R3 is supervision for transfers and supervision for locomotion and mobility at times. R3's Fall Risk assessment dated [DATE] documents a score of 12, which indicates R3 is at risk for falls. The facility fall risk assessment does not document if someone is at low, moderate, or high risk for falls. It documents if someone is at risk or not at risk for falls. R3's undated Care Plan documents a Focus area of I am at High risk for falls r/t (related to) dementia, reduce safety awareness and wandering behaviors. Goal: All falls will be reviewed by the IDT (Interdisciplinary Team) through next review, Interventions: Be Sure R3's call light is within reach and encourage the resident to use it for assistance as needed (date initiated 4/29/19). The resident needs prompt response to all requests for assistance (date initiated 4/29/19). Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (date initiated 4/29/19). Encourage R3 is (sic) wearing appropriate footwear non-skid socks or shoes when ambulating as he allows (date initiated 7/13/2020). Encourage R3 to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: walking to meals and activities (date initiated 4/29/19). Ensure rolling desk chair is securely pushed up under desk. Place stationary chair behind nurse's station (date initiated 12/15/21). Night light added to R3's room to decrease falls (date initiated 10/19/22). Remove all tripping hazards from room at this time (date initiated 3/4/20). Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (date initiated 4/29/19). R3 needs activities that minimize the potential for falls while providing diversion and distraction (date initiated 12/27/19). R3 room relocated closer to nurse's station to increase monitoring (date initiated 9/12/22). Sign (tractor) to be put on R3's door to assist him while finding is (sic) room (date initiated 12/17/19). Staff educated to make sure all personal items including water glass on the bed side table are in reach when in bed (date initiated 5/2/19). Staff to ensure that R3 has all items in reach when eating (date initiated 4/13/20). Staff to offer assistance when R3 is ambulating as he will allow (date initiated 10/10/22). A) R3's progress notes documents, 9/9/22 6:25 PM Resident had a witnessed fall 09/09/2022 6:25 PM Location of fall: Residents room, Res (resident) found on floor in room and noted to have a small laceration to back of head, approx. (approximately) 3 cm. Area slightly raised, dry drsg (dressing) applied. Resident assisted up and onto bed. Refuses to stay in bed, gait is unsteady and leaning backwards. No other signs of injuries present on 09/09/2022 6:25 PM. Assessment Unwitnessed fall, neurological checks initiated. Alert and disoriented per usual baseline. No changes in range of motion from normal baseline. New injury observed. Laceration to back of head approx. (approximately) 3 cm. Actions Taken: Dry drsg to back of head. Assisted into bed but refuses to stay. Interventions: Mattress put on floor. This progress note documents the fall as both witnessed and unwitnessed. The note then documents R3 was found on the floor in his room indicating it was an un-witnessed fall. R3's neurological (neuro) checks were reviewed, and documents neuro assessments were completed on 9/9/22 at 6:40 PM, 6:55 PM, 7:25 PM, 7:55 PM, 8:05 PM, 8:35 PM, and 12:00 AM. Neuro checks were documented as completed on 9/10/22 at 12:35 AM and 8:35 PM. All neurological checks documented have vital signs dated 9/9/22 at 6:25 PM and a pain assessment dated [DATE] at 2:48 AM. This indicates R3 did not have neurological checks done 10 times during the 72-hour post fall period. The neurological checks also document R3's vital signs and pain assessment were completed once in the same 72-hour post fall period. R3's Fall IDT (Interdisciplinary Team) Note dated 9/12/22 10:10 AM documents, Resident observed laying on floor in room, noted to have hematoma and laceration approx. 3 cm to back of head. Moves all ext (extremities) without difficulty or c/o (complaints of). Hollering get me up. Denies any c/o (complaints of) of discomfort. Neuro checks initiated and WNL (within normal limits). Assisted up x (times) 2 staff and amb (ambulated) to bed. Refuses to stay in bed. Ambulating per self, gait is unsteady, and resident is leaning backwards when walking. Root Cause of fall: Resident lost balance, ambulating without assistance. Intervention and care plan updated: Resident moved to room right across from nurse's station for increased monitoring. On 10/20/22 at 9:52 AM, V15 (Licensed Practical Nurse/LPN) stated one-night (date unknown) R3 fell and bumped his head and she put his mattress on the floor that night. V15 stated R3 had a 2-3 cm laceration on the back of his head. V15 stated she did neuro checks, fall monitoring, and behavior monitoring, called the physician, and gave R3 snacks. When asked how putting the mattress on the floor helped, V15 stated, Well he wasn't able to get up. V15 stated she was the only one on that unit and she wasn't able to properly supervise R3. V15 stated the CNA (Certified Nursing Assistant) working with her on that night got sick and left the facility around 2:00 AM. V15 stated she tried to call people in, but no one was able to. V15 stated it is not typical to only have one staff member working on the unit. On 10/20/22 at 12:46 PM this surveyor informed V2 (DON/Director of Nurses), of V15's interview of putting R3's mattress on the floor and V15 saying R3 couldn't get up. V2 stated she wasn't aware of them only having one nurse on the unit and no CNA's. V2 stated she would expect facility staff to call her if that happened. V2 stated she would consider putting R3's mattress on the floor a restraint and R3 isn't assessed for needing restraints. A statement by V15 dated 10/20/22 that was provided to this surveyor by V1 (Administrator) and V2 (DON) documents, I spoke with the state surveyor concerning R3 the night he fell, I was alone on unit as the CNA scheduled was sick and left. R3 was restless, refusing to stay in bed. I told her he was restless, refusing to stay in bed. I also had told her I walked with him, gave him snacks and attempted to sit with him to calm him down. Ineffective. He was leaning backwards while walking and balance was very poor and put his mattress on floor for his safety r/t (related to) balance and restlessness and attempting other redirection without success. On 10/21/22 at 12:02 PM, V20 (RN/Registered Nurse) stated she had never seen R3's mattress on the floor. V20 stated R3 would be able to get up from the floor without assistance. V20 stated she had never seen R3 get up from the floor, but he got out of his bed that was in a low position without assistance. On 10/26/22 at 1:08 PM, V23 (MDS Coordinator/Certified Restorative Nurse) stated he does restorative assessments on the residents and last assessed R3 on 9/14/22. V23 stated he saw R3 walking in the hallways after that assessment and wasn't aware of a decline in his functional capabilities. V23 stated he believed R3 could get up off the floor. V23 stated he believed R3 would have to crawl to some type of support to get up but that he could get up, once he had the support of a bed, wall, or chair. On 10/21/22 at 1:55 PM when asked why R3's mattress wasn't still on the floor V2 (DON) stated they probably moved it after that because they came up with a different intervention. V2 stated they probably changed it because it didn't work, and they didn't want R3 to trip over it. On 10/26/22 at 9:41 AM when asked about R3's mattress being put on the floor, V1 (Administrator) stated, she (V15) ensured the safety of the resident. V1 stated he was good with the mattress being on the floor, if it was being used as a safety measure, but he thought increased monitoring would ensure that, so you didn't have to put the mattress on the floor. When asked if he was aware the CNA had to go home and there was only one staff member on the unit V1 stated he was not. V1 stated there were three CNA's working on the other halls and they would have floated over to that unit to help. On 11/01/22 at 4:20 PM, V15 (LPN) stated on 9/9/22 after she had moved R3's mattress to the floor R3 was able to get off the mattress and did in fact get off it while she was working that night. V15 stated R3 crawled on his hands and knees to the door of his room and asked for help. V15 stated she had to go to the other side to get another nurse to assist her in getting R3 off the floor. V15 stated she did not believe it would have been safe for her to assist R3 off the floor by herself. V15 stated she put R3 back on his mattress that was still located on the floor, and she believed he stayed there the remainder of the night. When asked if that was the only time another staff member came to the unit to assist her, V15 stated the other nurse came over to the unit around 5:30 AM so she could go to the other side to pass medications. When asked if she notified V1 or V2 she was the only staff working on the unit V15 stated the other nurse made the calls since she had been working at the facility longer and she knew she had attempted to call staff in but wasn't sure if she had attempted to call V1 or V2. B) R3's unwitnessed fall report dated 9/23/22 documents, R3 was asleep in room with door to room closed. CNA (Certified Nursing Assistant) was sitting at the nurse's station desk and she seen the resident open up his door. The resident had blood all over himself, the floor, and his bed, appearing to come from an open area on the back of his head, that also includes a knot area. Resident unable to give description. Description: The CNA called this nurse. and this nurse preformed an assessment, as able, due to resident's dementia and combative behavior. He appeared to be alert with confusion, able to stand and walk around and get in and out of his bed. The blood appeared to come from an open area to the back of his head. His vital signs were taken and he was assisted to the shower by 2 CNA's. Resident was very angry with getting a shower, he was yelling and hitting staff while shower was in progress Resident taken to hospital: Laceration back of head R3's Fall IDT Note dated 9/23/22 documents Intervention and care plan updated: Staff education for making sure door is open when not doing resident care. R3's neurological checks were reviewed, and documents neuro assessments were done on 9/23/22 at 3:45 AM, 6:30 AM, 10:30 AM, 2:30 PM, 6:30 PM, and 10:30 PM; and on 9/24/22 at 2:30 AM, 6:30 AM, and 2:30 PM, 9:25/22 at 6:30 AM and 2:30 PM. This indicates R3 did not have neurological assessments completed 7 times in the 72-hour post fall period. C) R3's 10/08/22 witnessed fall report documents, R3 was walking down hall and lost balance and fell to right side onto floor, resident did not hit head. Immediate Action Taken: Resident trying to get self-up, staff helped resident up after assessed. No injuries at time of incident. R3's Fall IDT Note dated 10/10/22 documents, Intervention and care plan updated: Staff to assist resident with ambulation as he allows. D) On 10/18/22 at 6:42 AM, R3 was observed walking the length of the dining room and out into the hallway. R3 was wearing pajamas and no shoes. R3 was unsteady and stumbling some during this observation. R3 had dried blood on his shirt on the top of his left shoulder, on his left ear, and on his neck behind his left ear. There were no staff observed in the dining room or in the hallway. This surveyor noted V7 (CNA) behind the nurse's station in a small room eating breakfast. This surveyor notified V7 of the blood and she stated she thought the blood on his shirt was dried blood. This surveyor agreed with her that it was dried blood and pointed out the blood on R3's ear and neck. V7 stated she didn't know if it was something new and walked with R3 to a room located down the hall, not near the nurse's station. She then went back to the small room behind the nurse's station and began eating. R3 was observed two more times throughout the day on 10/18/22, both times he was in bed. Immediately following this observation and throughout the day on 10/18/22, R3's medical record was reviewed and did not document incident reports, assessments, or follow up related to the dried blood on R3's left ear/neck. On 10/18/22 at 1:30 PM, V7 (CNA) stated R3 had been really combative on 10/18/22. V7 stated they told the nurse about his ear, and she thinks maybe he scratched it. V7 stated they tried cleaning his ear, but he wouldn't let them. When asked if she was aware of any recent fall, V7 stated, there was nothing in report and nothing happened on day shift on 10/18/22. (The most recent fall documented in R3's record was on 10/08/22.) On 10/20/22 at 6:30 AM, V13 (LPN/Licensed Practical Nurse) stated she didn't know what happened to R3's left ear. On 10/21/22 at 10:05 AM, V18 (CNA) stated she had provided care to R3 but not when he had any falls. When asked if she knew what happened to R3's ear V18 stated she had no clue. On 10/20/22 at 11:51 AM, V17 (LPN) stated she worked on Tuesday 10/18/22. When asked if she knew what happened to R3's ear V17 stated, just what she was told, that he had hit it on his bed or something the night before. (There is no documentation in R3's medical record of him hitting his head on the bed on 10/17/22). On 10/20/22 at 12:46 PM when asked about the injury to R3's ear V2 (DON) stated there was always an ongoing investigation for R3. When asked if I could see the investigation V2 stated she didn't have anything written on it that she could give me. After this interview V2 provided this surveyor with the following documentation on 10/20/22. R3's Skin Tear report dated 10/18/22 4:45 PM documents, Resident ambulating falling back to hit the closet door with his left arm causing multiple skin tears to upper-elbow-forearm of left arm, wounds cleansed with wound cleanser non adhere drsg (dressing) applied arm wrapped with cling wrap and secured with tape. R3's Progress note dated 10/18/22 at 5:22 PM Resident has been very restless, hitting the doors and walls with his hands, difficulty with sitting still, resident was in his old room and fell back against the closet doors and caused skin tears to back side of upper middle and lower left arm, combative with staff when trying to provide care, hitting, kicking, pinching, and biting at staff. Notified V4 (Physician) with new order received to give PM dose of Valium now and hold tonight dose. Notified ADON (Assistant Director of Nurses) and POA (power of attorney) of health care with a return call from (family member) with update on condition. Staff assist to DR (dining room) for supper meal resident unable to sit long enough to eat, carried around bowl of peas to eat. The skin tear report dated 10/18/22 at 4:45 PM and the progress note dated 10/18/22 at 5:22 PM indicate R3 did not have documentation in his medical record related to a fall prior to the observation on 10/18/22 at 6:42 AM that would account for the dried blood on his ear/neck. Upon requesting the investigation for the areas on R3's neck/ear this surveyor was provided with the following progress note. R3's 10/20/22 8:48 AM progress note documents, Resident had fall, struck side of bed on LT (left) side of head, scratches to LT side of ear which is consistent with striking head on bed on LT side, Injury with dried blood was noticed within one day, healing was already taking place which is consistent with time of fall. This report has handwritten on it, From 10/18/22 fall This information is consistent with the information provided by V17 (LPN) in her interview on 10/19/22 at 11:51 AM. There is no other documentation in R3's medical record related to follow up, neurological checks, or new interventions related to a fall where R3 hit his head on his bed. R3's Injury of Known report with the date cut off and not readable documents Resident had a fall where he struck the left side of his head, scratch is on left side of head. This report was given to this surveyor with R3's progress notes dated 10/20/22 8:48 AM, attached to it. When asked for a copy of this report with the date viewable received the following risk management report from V2. R3's Risk Management report dated 10/20/22 8:48 AM documents, Resident had a scratch to left ear. Under Description of Action Taken the report documents, Resident had a fall where he struck the left side of his head, scratch is on left side of head. On 11/02/22 at 4:32 PM, V1 and V2 were asked to clarify the discrepancies in the progress notes, skin tear report, and risk management report. They stated they would see what they could find. As of 11/03/22 they had not provided this surveyor with any other information. On 11/04/22 at 9:49 AM spoke with V1 and V2 and explained that I needed clarification related to the different reports on R3's fall related to the area on his ear. V2 stated she had sent me the report with handwritten information at the bottom of the report. V2 stated she would see what else they had and send it to me. On 11/04/22 at 11:46 AM received an email with an Investigation of Skin Tear, Bruises, and Abrasions attached dated 10/18/22. The report documents the location as left ear with no description of injury documented. The report documents R3 had several recent falls et (and) behaviors. Handwritten at the bottom of the report it documents, We do weekly skin assessments, done 10/11/22, then 10/18/22. After wound was cleaned, it was a small scratch. R3 has many behaviors, including beating on walls and doors, tearing fixtures off of wall. R3's frequently taking clothes off, refuses to have nails trimmed, so resident does scratch self often. Scratch is consistent with resident behavior. Blood spot was found on resident pillowcase, consistent with scratch. On 11/4/22 at 12:50 PM spoke with V1 and V2 related to the information provided in the email dated 11/4/22 at 11:46 AM. V2 stated R3 did not have any behaviors or falls on 10/17/22. V2 stated the skin tear report dated 10/18/22 at 4:45 PM and the progress note dated 10/18/22 at 5:52 PM are referencing the same incident that occurred at 4:45 PM. V2 stated she thinks the progress note dated 10/20/22 at 8:48 AM was when she was talking with nurses and trying to determine where the dried blood on R3's ear and neck had come from. V2 stated she assumed it came from the other fall. When asked what other fall she was referencing she stated the nurses had told her R3 had fallen by his bed. V2 then stated R3 didn't actually fall and hit his head on his bed, but she believes he scratched his ear while in bed. E) R3's progress notes document the following on 10/19/22 at 7:27 AM Resident up and down this shift, after fall resident made one on one so he would have supervision to prevent further falls, no s/s (signs of symptoms) of distress noted will cont (continue) to monitor. This is signed by V13 midnight shift nurse and is not documented as a late entry. R3's progress note dated 10/19/22 at 8:05 AM Nurse contacted MD (physician) about resident behavior. New order rec'd (received) to give Valium early et (and) hold bedtime dose. This is signed by V2 (DON). On 10/19/22 at 10:30 AM this surveyor with V8 (CNA) present observed R3 lying in bed. R3 had a large red and purple hematoma on the left side of his head that went from the top of his forehead down his nose and across his face covering his left eye. When asked what happened V8 stated R3 had fallen last night but she didn't have any of the details. R3's Un-witnessed fall report dated 10/18/22 at 6:30 PM documents This nurse was at nurse's station getting report, other nurse helped resident to bed, staff heard resident yelling help sitting in floor on bottom, trying to get up, resident noted to have hematoma to left forehead. Under description the report documents resident helped to feet and bed; ice applied to forehead. R3's 10/19/22 3:47 PM Fall IDT Note documents, This nurse was at nurse's station getting report other nurse helped resident to bed, staff heard resident yelling help sitting in floor on bottom, trying to get up, resident noted to have hematoma to left forehead. Root Cause of Fall: Resident in dark room. Intervention and care plan updated: Night light placed in resident's room to better see when room is dark. On 10/20/22 at 6:30 AM, V13 (LPN) stated she was working recently (unsure of date) when R3 had a fall. V13 stated they were in the middle of report, and she got up because R3 had been walking to the door and she put R3 in bed. V13 stated she continued to give report and then heard R3 say help me. V13 stated R3 was sitting on his bottom with a hematoma on his forehead. V13 stated she had one of the girls sit with him one to one after that and made sure the chairs were out of his room. On 10/19/22 at 11:51 AM when asked if she felt they had enough staff to provide care for R3, V17 stated, No I think he would need to be 1:1 to prevent falls and/or behaviors. On 10/19/22 at 1:35 PM, V12 (LPN) stated R3 did not have one to one ongoing but they are doing frequent checks on R3. V12 stated the one to one stopped about 7:00 AM on 10/19/22. On 10/21/22 at 1:55 PM when asked how R3 fell and got a hematoma to his head on 10/19/22 if he was 1:1, V2 stated, That is a good question. When asked if he was supposed to be 1:1 at the time of the fall on 10/19/22, V2 stated they had sitters for R3 since the night of 10/18/22. When asked if she knew where R3's one to one sitter was when he fell on [DATE], V2 stated she hadn't looked into it yet. Reviewed R3's progress notes with V2 and she stated he should have been one to one at the time of the second fall. V2 then stated she doesn't know where the nurse got the order from and R3 probably fell during report. On 10/25/22 at 12:19 PM when asked if she had any more information on R3 having a 1:1 sitter when he fell on [DATE], V2 stated she did not. V2 stated she knew the staff kept an eye on R3 but there was no documentation of 1:1 monitoring. When asked if he was supposed to be 1:1 monitoring at the time of the fall V2 stated, Yes the nurse had implemented it. When asked if there was someone with R3 when he fell V2 stated he would have been right there, someone would have been close to him. When asked if there was a staff member right with R3 when he fell V2 stated it didn't seem like it. V2 stated she couldn't say for sure since she wasn't there, but it wasn't documented. On 10/26/22 at 12:46 PM, V1 (Administrator) stated R3 was made 1:1 short term on night shift on 10/18/22 after he fell and that when the IDT team met, they changed the intervention to a place a night light in his room since it was dark. V1 stated any resident who is to be placed 1:1 would be approved through him so he could get more staff to assist with monitoring and R3 had not been one to one other than the short time after a fall. This indicates R3's progress notes document on 10/19/22 at 7:27 AM R3 had a fall and the intervention implemented was 1:1 staff. R3's un-witnessed fall report documents the fall on 10/18/22 at 6:32 PM. R3's 10/19/22 7:27 AM progress note does not document if it is a late entry and referencing the fall on 10/18/22 at 6:32 PM. V2's interview documents R3 was 1:1 with sitters beginning on 10/18/22. V2 did not investigate if R3 was supposed to have had a 1:1 sitter and if so where the 1:1 sitter was at the time of the fall on 10/19/22. F) On 10/19/22 at 3:45 PM, R3 was observed sitting on the side of a bed with no sheets on it, wearing torn pajama pants, a dressing was observed to R3's left hand, a hematoma to R3's left forehead, left cheek and left eye area is black/red/blue. R3 doesn't speak to this surveyor. There is a recliner next to the bed with the footrest raised and blankets in the recliner. V31 (LPN) was present with this surveyor and stated to R3 that he had gotten out of the recliner. V31 attempted to redirect R3 when he stood up from the bed. R3 was very unsteady on his feet. R3's soles of his feet were either bruised or dirty and there were scratches observed on the side of R3's left foot. R3's progress notes document on 10/11/22 at 10:00 PM, Weekly skin observation completed for R3. Skin is warm, dry, within normal limits. Skin turgor is good. Skin Concerns: Skin concerns observed: Back of head-scabbed area from recent fall. No s/s of infection. No swelling, Skin concerns observed are not new. This skin assessment does not document any other areas observed to R3's skin. R3's progress notes document on 10/19/22 at 4:01 PM Skin assessment completed today and V4 (Physician) notified for treatments for skin tears. Skin tear noted left wrist, old skin tear noted to left second digit and slight bruising starting around it. 3 skin tears noted near left elbow area, left upper forearm has a skin tear, old skin tear noted on right wrist, bruise noted on left shoulder area pinkish purple in color, right lower back has a small scab noted, abrasion noted behind left ear/neck, left lower ear lobe has a small open area like skin tear, bruising pinkish purple noted to center of upper chest, right buttocks and right post thigh has bruising and it is spreading to other side of buttocks and starting to go down scrotum and lower back, back of scalp has a small scabbed area left eye and cheek and forehead has dark purple pinkish red bruising and eye lids are swollen and left eye is reddened, right lower ext (extremity) has a small scab approx. (approximately) 1.5 cm ( centimeter), left lower ext has a small scab approx. 0.5 cm long, few small scattered bruises noted to bil (bilateral) hands, pinkish purple bruising noted to right temple area and right side forehead. On 10/20/22 at 6:30 AM when asked if they had enough staff to provide care for R3, V13 (LPN) stated, Sometimes. V13 stated lately R3 had not been easily redirected and she thinks it started when he started the Valium. V13 stated R3's feet aren't bruised they are just dirty because he refuses to cover his feet On 10/26/22 at 9:41 AM when asked if he investigated the injuries of unknown origins including the bruises noted on R3's skin assessment from 10/19/22, V1 (Administrator) stated they were just going by the several falls that he had and his picking. V1 stated R3's behaviors have been escalating for the past month. When asked how he knew the injuries came from the falls/behaviors and didn't come from abuse, V1 stated, I interview, I look at the bruising, the type of bruising, and determine if it is consistent with the fall. When asked for that investigation documenting those findings, V1 stated he didn't have one in writing, but he could write it up for me. On 11/0/1/22 at 5:36 PM, V1 provided this surveyor with the following investigations: R3's Investigation of skin tear, bruises, abrasions dated 10/18/22 documents left ear under location with no type or description of injury documented. The areas of First noted by whom, Date, Time, Date/Shift of last shower, and transfer status, Equipment, any new assistive devices or equipment, any signs/symptoms of infection, Resident interview, Most likely cause, Staff interviews conducted, New intervention, Care plan updated, Investigation Completed by, Date, and Reviewed by Administrator are all blank. Under Recent Fall or injury-date and specifics it documents, several recent falls et (and) behaviors. Handwritten at the bottom of the report it documents, We do weekly skin assessments, done 10/11/22, then 10/18/22. After wound was cleaned it was a small scratch. R3 has many behaviors including beating on walls et doors, tearing fixtures off of wall. Resident frequently taking clothes off, refuses to have nails trimmed, so resident does scratch self often. Scratch is consistent with resident behaviors. Blood spot was found on resident pillowcase consistent with scratch. V1 (Administrator) verified via email on 11/07/22 at 11:49 AM the skin assessment referred to in this investigation is the same as the assessment dated [DATE]. V1 stated the assessment was started on 10/18/22 and completed on 10/19/22. R3's Investigation of Skin Tear, Bruises, and Abrasions dated 10/08/22 documents a bruise to right posterior thigh. Under description of area, it documents right side. Under Resident Fall or injury- date and specifics the report documents, Resident had recent fall 10/8/22 in hallway landing on right side. The following areas are blank on the report, Recent IV therapy, Recent LOA (leave of absence) with family, Equipment, any new assistive devices or equipment, any signs/symptoms of infection, Resident interview, most likely cause, staff interview conducted, new interventions implemented, and care plan updated. With no person documented under Investigation completed by and no date of completion documented. R3's Investigation of Skin Tear, Bruises, and Abrasions dated 10/19/22 documents a bruise to left buttocks noted on 10/19/22. Under Recent Fall or injury- date and specifics the report documents, had recent fall in room landing on buttocks. The remainder of the report is blank except the resident interview is marked as NA and reviewed by DON (Director of Nurses) and Reviewed by Administrator has signatures. The areas of staff interviews, equipment observed, most likely cause, and investigation completed by, and date are all blank. At the end of the report the following is handwritten in, Due to recent falls IDT (Interdisciplinary Team) team and family (POA) send to (name of mental health hospital) for med review. R3's Investigation of Skin Tear, Bruises, and Abrasions dated 10/19/22 documents a bruise to left 2nd digit noted on 10/19/22. Under Recent Fall or injury -date and specifics the report documents, had recent fall hitting closet door and hits second doors. The areas of s[TRUNCATED]