**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify causes of resident weight loss; failed to identify that a resident had AIDS (acquired immunodeficiency syndrome); failed to monitor R3's HIV diagnosis according to professional standards; failed to develop a plan of care to address known weight loss and refusals of care; failed to notify providers of abnormal lab results; failed to notify providers of severe weight loss; failed to follow physician orders for lab work; failed to notify the provider/implement dietician recommendations timely. These failures affect 1 resident (R3) reviewed for quality of care. These failures caused harm to R3 as evidenced by a 5.5% weight loss in 6 days, an 8.2% weight loss within a month and a 16% weight loss within 3 months.Findings include:R3's face sheet documents in part a diagnosis of HIV (Human Immunodeficiency Virus) hemiplegia and hemiparesis of the right side, memory deficit following unspecified cerebrovascular disease, and schizoaffective disorder. R3's significant change MDS (minimum data set) (6/6/2025) documents R3 has a brief interview of mental status (BIMS) summary score of 10, indicating that R3 has moderate cognitive impairment and R3 has had weight loss that was not prescribed by the physician. On 6/30/2025, an additional BIMS assessment was completed for R3 with a summary score of 6, indicating new cognitive decline and severe cognitive impairment. R3's laboratory testing indicates on 5/17/25, R3 had abnormally low CD4 (Cluster of Differentiation 4) levels of 151 uL (microliter.) No laboratory values for R3's HIV viral load were noted within the medical record and were not provided by the facility prior to the end of the survey. R3's medication administration record (MAR) dated June 2025 documents R3 refused medications for HIV treatment 14 times in 1 month. R3's documentation of R3's weights is as follows:-12/5/2024 106 lbs (pounds) -1/3/2025 105 lbs-3/3/2025 105.6 lbs-4/4/2025 106.4 lbs-5/7/2025 101.8 lbs (-4.3% weight change from comparison weight 4/4/2025) -5/26/25 97.6 lbs (-4.1% change from 5/7/2025; -7.6% change from 3/3/2025) -6/5/2025 97.8 lbs (-8.1% change from 4/4/2025) -6/11/2025 95.2 lbs (-10.6% change from 4/4/2025, -10.4% change from 12/5/2024)-6/17/2025 90 lbs (-5.5% change 6/11/2025, -8.2% from 5/26/2025, -15.4% from 4/4/2025)-6/24/2025 89.4 lbs ( -16% from 4/4/2025, -9.2% from 5/26/2025, -15.2% from 1/3/2025)R3's progress notes document V9 (Infectious Disease (ID) Nurse Practitioner (NP)) visited R3 on 5/13/2025 for R3's diagnosis of HIV and gave the following orders: .-Order CD4 and viral load, -Monitor CBC (Complete Blood Count), CD4 and viral load, -Staff to continue to monitor, -Inform PCP (Primary Care Physician)/PCNP (Primary Care Nurse Practitioner) or ID if acute change in condition or fever . There is no evidence the viral load order was carried out by the nursing staff. On 5/16/2025, V14 (Registered Nurse) reached out to V7 (Physician) and notified V7 of a change in condition described as functional decline including refusals of medications, decreased appetite, refusing food/drink. V7 responded to V14 and stated that V7 would come visit the R3 and to follow up with Infectious Disease MD (medical doctor). On 5/20/2025, V7 was notified by V14 of R3's change in condition described as decrease in appetite, refusing meds, not wanting to get out of bed and a general change in mental status. V7 reviewed the abnormal CD4 lab values and assessed the resident and ordered the resident to be sent to the hospital for further assessment for altered mental status. The abnormal CD4 laboratory results or diagnosis of acquired immune deficiency syndrome (AIDS) was not identified by V7. R3 was hospitalized from [DATE] until 5/23/2025 for a urinary tract infection. On 5/27/2025, V9 (Infectious Disease Nurse Practitioner) visited R3 and did not review the abnormal CD4 lab. On 6/6/2025, a significant change was identified by the facility and a significant change MDS was completed by the facility's interdisciplinary team. On 6/6/2025, V8 (Physician) assumed care from V7 and completed a visit with R3. During this visit, V8 did not identify the abnormal CD4 values resulted on 5/17/2025 and did not identify that R3 had AIDS. On 6/10/2025, V6 (Registered Dietician) identified that R3 had weight decline, was concerned with adequate by mouth intake and recommended an appetite stimulant if not contraindicated. There is no documentation that this recommendation was communicated to a provider. On 6/20/2025 (documented on 6/25/25), V8 examined R3 and identified significant weight loss, failure to thrive, HIV and ordered in response: (unknown medication) Consider starting dose: 7.5 mg at bedtime Can be titrated based on response and tolerability, usually in 7.5?15 mg/day range for appetite. There is no documentation in the progress notes that indicates that the significant weight loss warnings from 5/7/2025, 5/26/2025, 6/5/2025, 6/11/2025, 6/17/2025, and 6/24/2025 were communicated to a provider. On 6/25/2025 at 1:15 PM, R3 was observed lying in bed and appeared cachexic. R3 had unintelligible speech at this time while trying to conversate.On 6/25/2025 at 1:49 PM, V5 (Restorative Nurse, Licensed Practical Nurse) affirmed that V5 is responsible for monitoring weights within the facility and addressing weight loss. V5 explained that R3 has had significant weight loss since May of 2025 and that the dietician was aware. R3 has been refusing meals and the facility does not know the cause of R3's decreased appetite. V5 stated, nothing seems to be working. We don't really know why. V5 affirmed that R3 has had significant decline. On 6/26/2025 at 10:15 AM, V2 (Director of Nursing) stated that V2 was aware that R3 had weight loss but was unsure of the cause of the weight loss. Surveyor reviewed the abnormal CD4 result (5/17/2025) with V2 (Director of Nursing) and V2 affirmed that V7 (Physician) reviewed the laboratory result. V2 denied knowledge of the result, affirmed that the resident could have AIDS, and was unsure if V7 had identified the abnormal CD4 level. V2 denied any knowledge that R3 was ever diagnosed with AIDS or if AIDS had ever been identified for R3. V2 affirmed that AIDS is life-threatening, can cause weight loss, and patients with AIDS have unique care needs in comparison with a resident with HIV. V2 stated that notifications of changes in a resident's health status made to the provider and family should be noted within a resident's progress notes. V2 was unsure of how often the facility was monitoring R3's CD4/HIV viral load. V2 affirmed that the last time R3 had lab work related to R3's HIV diagnosis was 1/28/2024. The facility was unable to provide additional documentation for lab monitoring prior to the exit. R3's physician orders do not document any active standing orders for regular monitoring of R3's CD4 and HIV viral load. On 6/26/2025 at 11:38 AM, V10 (Infection Preventionist, Licensed Practical Nurse) affirmed that V10 was aware of R3's HIV diagnosis. V10 reviewed R3's medical record and affirmed there was no active orders to monitor CD4 counts or Viral Load and that the 5/17/25 lab was abnormal for CD4. V10 reviewed R3's progress notes and providers documentation including but not limited to, V7 (Physician), V8 (Physician), V9 (Infectious Disease Nurse Practitioner) and V17 (Nurse Practitioner) and affirmed that the lab value was not addressed and that AIDS was not identified by any of R3's practitioners. V10 stated that AIDS can cause weight loss, increases their risk of opportunistic infections and places them at risk for death. On 6/26/2025 at 11:25 AM, R3 was observed lying in bed and V11 (MDS Nurse, Registered Nurse) affirmed that R3 had sunken in cheek bones, visible ribs, and sunken in areas around R3's collarbones (symptoms of cachexia, muscle wasting). When R3 was asked if R3 had lost any weight, R3 shook R3's head indicating yes. V11 affirmed that the facility is aware of R3's significant weight loss but was not sure the cause of the weight loss. On 6/26/2025 at 12:01 PM, V6 (Registered Dietician) affirmed that V6 is the dietician contracted to the facility. V6 stated that V6 was familiar with R3 and has a history of weight loss. V6 explained that R3 continues to lose weight despite having as many supplements as we (the facility) can provide. V6 had been told from staff that R3's appetite was poor so V6 recommended an appetite stimulant on 6/10/2025 to address the weight loss if the medication was not contraindicated. V6 stated that the facility needed to review that recommendation with a medical provider and that V6 expects when recommendations are made that they are communicated timely. V6 believed that R3 could have greatly benefited from an appetite stimulant to address R3's weight loss. Surveyor reviewed R3's lab work with V6 and V6 stated I (V6) had no idea that R3 had AIDS. I don't look at labs like that (CD4), I only look at labs like electrolytes. I rely on nursing or the providers to communicate information to me like that. AIDS can cause significant weight loss and cause decreased appetite. (R3) having AIDS would make perfect sense as the cause of his weight loss and lack of appetite! Now that I know (R3) has AIDS, I would say the root cause of (R3's) weight loss is the AIDS. R3's weights were reviewed with V6 and V6 affirmed that R3 has had severe, unintended weight loss.On 6/26/2025 at 12:54 PM, V8 (Physician) affirmed that V8 is the primary care provider for R3 and assumed care after V7 (Physician) on 6/1/2025. V8 stated that a CD4 <200 units/liter indicates that a patient has AIDS. V8 affirmed that treatment for AIDS vs. HIV differs, that AIDS can cause weight loss, and that AIDS is a life-threatening condition. V8 affirmed that V8 was aware that R3 had a diagnosis of HIV but was unsure of who was following/treating R3's HIV. V8 explained that V8 defers to an infectious disease consult to manage HIV. R3's CD4 laboratory testing was reviewed with V8 and V8 affirmed that the CD4 level indicated that R3 had AIDS. V8 denied any knowledge of R3's CD4 levels prior to the interview and was never told that R3 had AIDS. V8 stated R3's weight loss certainly could be caused by AIDS and that AIDS would cause the lack of appetite and changes in condition that R3 had been experiencing. V8 stated that V8 was not notified of the dietician recommendation of an appetite stimulant until V8's visit with R3 on 6/20/2025 (the medication was not administered until 6/30/2025). V8 stated that the facility should be notifying V8 with weight loss and dietician recommendations. V8 explained that R3 frequently refuses medications/care and that this can place R3 at risk for AIDS and HIV-resistant infections. V8 affirmed that a plan of care should have been developed in response to R3's weight loss and refusals of HIV medication. V8 explained that the standard of care for monitoring a patient with HIV is a CD4/HIV viral load no longer than every 6 months. When the surveyor notified the physician that the last time the facility had documentation the CD4 was tested was 1/2024, V8 replied (R3) is lucky to be alive if (R3) had had AIDS this whole time. V8 explained that V8 has reviewed hospice care with R3 and stated, I (V8) think (R3) is even more appropriate for hospice care now that I know (R3's) failure to thrive is caused by AIDS. Review of R3's care plan does not document any identification, goals or interventions related to R3's identified weight loss and does not document any interventions of weight monitoring in R3's HIV care plan. A refusal of care and weight loss care plan was added on 6/27/2025 (after the start of the survey). On 6/26/2025 at 1:08 PM, V12 (MDS Nurse, Registered Nurse) reviewed R3's medical record, affirmed that there was not a weight loss care plan in place for R3, no monitoring of weight related to R3's HIV diagnosis, and that R3's care plan should have addressed R3's significant weight loss. V12 stated that the purpose of the care plan and the resident assessment process is to identify resident needs and have a plan in place to address their problems. V12 reviewed R3's weights and affirmed that R3 has had significant weight loss. V12 stated when weight loss is identified, the provider should be immediately notified to address the weight loss and a plan should be put in place. On 6/26/2025 at 3:01 PM, V1 (Administrator) stated that V7 no longer has a relationship at the facility due to care concerns. V7 was attempted to be reached via phone on 6/25/2025 and 6/26/2025 and was unable to be reached. On 6/30/2025, R3's MAR documents an appetite stimulant (Mirtazapine 7.5 mg (milligrams)) was started (20 days after V6 gave the recommendation). On 6/30/2025 at 9:31 AM, V9 (Infectious Disease Nurse Practitioner) affirmed that V9 is the rounding infectious disease provider at the facility and that V9 sometimes rounds on HIV positive patients or they go to the specialized center. V9 recalled seeing R3 during rounds in May and asked V10 (Infection Preventionist, Licensed Practical Nurse) which provider was managing R3's HIV diagnosis. V10 told V9 that V10 was unsure and that V9 could follow so V10 put in labs. V10 stated that the standard of care for HIV positive patient lab work is a CD4 and viral load is drawn every 3 months but may need more lab work if they are unstable, maybe monthly. V9 denied that any staff member of the facility has communicated any concerns with R3's HIV diagnosis or results of the ordered lab work V9 had ordered. V9 stated, If the labs were abnormal or not collected, I would have expected the facility to call me. V9 explained that when a patient has a CD4 of less than 200 units/liter, the patient is considered to have AIDS. V9 stated that AIDS can cause weight loss, loss of appetite, opportunistic infections and is life threatening. Surveyor reviewed the lab work provided with V9 and V9 affirmed that R3 had AIDS. V9 stated, I had no idea of these lab results. The facility never told me that (R3's) CD4 was that low. I did not review the CD4 lab results when I visited (R3) on (5/27/25), I am not sure if the results were even available for me to view. I haven't had any calls or concerns about (R3's) HIV diagnosis or refusal of medications from the facility. They (the facility) should have told me, I could have changed his orders, like I would have also made sure psych was on board to manage the refusals of care. Refusing HIV meds can also put the resident at risk of developing AIDS. I wasn't made aware and didn't know the facility didn't follow my order for a viral load either. (V7) did not make me aware of the results either.On 6/30/2025 at 10:00 AM, V14 (Registered Nurse) stated that V14 is regularly assigned to care for R3 and was assigned to care for R3 today. V14 described that R3 has had a change in condition in June and explained that R3 has had very poor appetite, non-compliant with medications at times, and doesn't like to get up out of bed. V14 recalled reporting these symptoms to R3's physician (V7) and recalled that R3 was admitted for a UTI at the end of May (2025). V14 stated, (R3) is really declining. I have noticed that R3 has lost a little weight but restorative handles that. (R3) seems appropriate for hospice now due to the decline, (R3's) providers have been discussing it with (R3) lately. V14 stated that when a resident refuses care the provider needs to be notified immediately, especially if education doesn't work. V14 affirmed that restorative notifies the provider of weight changes but the nurses are responsible for communicating lab results to the providers immediately if they are abnormal. V14 stated that V14 was unaware of R3 having AIDS until the end of last week. V14 stated that AIDS can cause weight loss and is life threatening. V14 affirmed that if the facility was addressing the refusals of care or weight loss a plan would be developed in the care plan.On 6/30/2025 at 10:32 AM, V3 (Assistant Director of Nursing) affirmed that V2 (Director of Nursing) was not in the facility and that V3 is the acting director of nursing in V2's absence. V3 stated that the standard of care is that if weight loss identifies or triggers that the physician and dietician are notified, and that the documentation of this notification is made in the resident's progress notes. V3 reviewed R3's progress notes and affirmed that there is no documentation that any provider was notified about R3's weight loss. V3 stated that the facility should be notifying and documenting to the provider about R3's weight loss. V3 stated that the standard of care is that when weight loss is identified that a care plan is put into place to prevent further weight loss. V3 reviewed R3's care plan and affirmed that a care plan was created on 6/27/25 to address R3's weight loss and should have been created earlier when the weight loss was first identified. V3 stated that the standard of care for lab work is that the provider should be reviewing their lab work and abnormal lab values should be communicated to the provider for follow up. After, the notification should be documented within the resident's progress notes. V3 reviewed R3's progress notes and affirmed that V9 (Infectious Disease Nurse Practitioner) did not review R3's CD4 and the expectation is that V9 should be monitoring and following up on labs that V9 orders. V3 reviewed R3's records and V3 affirmed that there was no documentation that a provider was notified about R3's abnormal CD4 level that indicated AIDS and that the provider, should have been notified right away. V3 reviewed R3's progress notes and orders and affirmed that the dietician's recommendations for an appetite stimulant were not carried out until 6/30/2025. V3 stated that the recommendation should have been communicated to the provider right away and affirmed that R3 experienced a delay in care. V3 reviewed R3's orders and affirmed that V9's viral load lab order for R3 was not completed and that when providers give orders, they should be carried out. V3 stated, we should have known (related to the AIDS). R3's lab work documents on 7/1/2025 that R3's CD4 count was 75 uL (further decline from 5/17/2025). Facility policy titled, Weight Management (3/2022) documents in part, . It is the policy of this facility to monitor the nutritional status of all residents including all significant trending patterns of weight change to maintain acceptable standards of nutritional status . All significant, unplanned or trending weight changes must be investigated by the facility . In the case of significant or trending weight change, the following steps will be taken: A. Determine Possible Cause B. Determine Plan of Action C. Notify the Physician and responsible party . The Registered Dietician will assess each resident with a significant weight change and make appropriate recommendations to the physician . The Director of Nursing will refer all concerns and recommendations to the appropriate department for action. The Director of Nursing or designee will ensure physicians and resident representatives are informed of significant or trending weight fluctuations or concerns regarding a change in resident's nutritional status . Facility policy titled, Change in a Resident's Condition or Status (2/2025) documents in part, The Nurse will notify the resident's attending physician or physician extender when: .b. There is a significant change in the resident's physical, mental or psychosocial status c. There is a need to alter treatment significantly d. The resident repeatedly refuses treatment or medications .On 7/8/2025 at 12:00 PM, V2 (Director of Nursing) affirmed there is no facility policy for following physician orders.

Deficiency Text Not Available

Based on interview, observation and record review, the facility failed to develop and implement pressure ulcer prevention intervenctions for three of 12 residents (R49, R24, R120) reviewed for pressure ulcers. Findings include: 1. On 05/07/25 at 9:53 AM V4, LPN, said R49 has pressure wounds on her sacrum and legs. R49 said I can't move my legs, they stay like this. R49's legs contracted and knees touching with dressing on left and right knee. Pillow between legs, but knees still touching. On 5/8/25 at 1:41PM V2, Director of Nursing (DON) and V9, Wound Nurse, were interviewed together. R49 has a stage 4 pressure ulcer to her left knee that developed in house on 4/3/25. V9 stated all of R49's skin impairment locations. V2 said R49 is at high risk for skin breakdown they put a pillow between her knees and use wedges for positioning. Repositioning is done every 2 hours, we do that for everyone. V9 said R49 is not able to reposition herself. The surveyor asked for documentation of the skin prevention interventions used to prevent pressure on R49's knees. V2 said I will check the Treatment Administration Record (TAR) for documentation. The surveyor asked if the facility has avoidable/unavoidable risk assessment for pressure ulcers. V2 said I am not aware that we have those. V2 said the purpose of the avoidable/unavoidable risk assessment would be to ensure the facility has implemented all interventions possible to prevent further breakdown. On 5/8/25 when the TAR for R49 was presented the surveyor notified V2 that there is no treatment for the left knee until 4/11/25. On 5/9/25 at 9:30am V2 said the purpose of MAR/TAR is to make sure meds are passed and doing treatments. V2 said if not signed off then it was not done. On 5/9/25 at 11:16 AM V7, Nurse Practitioner, said R49 is generally declining, she had blood work, we have a consult going on for her workup to rule out cancer. V7 said they have measures such as using pillows and repositioning every 2 hours. V7 said 2 hours is the standard for repositioning for the facility. R49's diagnosis include but are not limited to Alzheimer's Disease, Chronic Kidney Disease, Venous Insufficiency, Convulsions, Diabetes, and Peripheral Vascular Disease. On 3/4/25 a wound evaluation completed states Blister front left knee, lateral, in house acquired. 6.28 x 2.96 Centimeters (cm). treatment identifies heel suspension/protective devices and mattress with pump. (Nothing written to treat the knee.) On 4/29/25 Focused Wound Exam for R49 states stage 4 pressure wound of the left knee full thickness, 5.2 x 3.6 cm. Treatment Administration Record for April 2025 does not have a treatment for the left knee impairment until 4/11/25. (Per interview and documentation, the impairment was found on 3/4/25.) Care plan does not address left knee pressure ulcer. There are no interventions included to address her knees. The physician pressure ulcer treatment policy dated 5/17 states residents with pressure ulcers will have a physician's order for treatment. The nurse will documents the treatment as given on the TAR. 2. R24 had the diagnosis of pressure ulcer of sacral region stage three (3), pressure ulcer of right elbow stage four (4) and functional quadriplegia. Physician order sheet dated 1/24/25 documents: low air loss mattress. Vital report dated 5/8/25 documents: weight 125.8 pounds. On 5/8/25 at 11:59am, R24 was observed in bed, on an air loss mattress with the setting on four hundred (400) pounds. V4 (nurse) said, R24's air mattress was set on four hundred pounds. V4 said, R24 is not four hundred pounds. A white plastic medical bracelet was observed wrapped around the air loss mattress control panel. On 5/8/25 at 1:16pm, V16 Assistant Director of Nursing (ADON) said, the air loss mattress should be set based on the resident's weight to prevent and treat pressure ulcers from getting worst. If the air mattress is set to high above or too low below the resident actual weight it will not help prevent pressure ulcers/wound from getting worst. On 5/8/25 at 1:37pm, V9 (treatment nurse) said, a medical band with the resident weight is place on the air mattress control panel. The facility's in-service dated 5/5/25 documents: Air bed settings are based on the resident's weight which can be found in the system. There are also wristbands located on the base of the board with weights. 3. On 5/7/25 at 1:15pm, R120 was observed on a regular pressure reducing mattress. V8 (nurse) said, R120 is on a regular mattress. R120 was not on an air mattress. On 5/8/25 at 2:36pm, V2, Director of Nursing (DON) said, if the wound doctor's make a recommendation for a low air loss mattress, it must be followed. On 5/9/25 at 12:39pm, V2 said, an air loss mattress is a pressure relieving mattress. Progress note dated 4/5/25 documents: spoke to R120's family who requested that patient have a consultation to be placed on an air mattress for bed sore prevention. She stated that R120 was on an air mattress in the previous facility she stayed in as well as in the hospital. Wound doctor note dated 4/8/2025 documents: Recommendation: Low Air Loss Mattress Pressure Ulcer Prevention Protocol dated 5/18/25 documents: All bed in the facility will have pressure reducing mattresses unless pressure relieving mattresses are required according to the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent development of a pressure ulcer; failed to promote wound healing and prevent infection for a dependent resident who was assessed as being at risk for pressure ulcer; and failed to perform weekly skin assessments as ordered. These failures applied to one (R1) of three residents reviewed for pressure ulcers and resulted in R1 developing a stage 4 facility acquired pressure ulcer to her sacrum, which required hospitalization for treatment of infection and surgical wound debridement. Findings include: R1 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her past medical history includes, but not limited to Local infection of the skin and subcutaneous tissue, dysphagia, peripheral vascular disease, pressure ulcer of sacral region stage 3, pressure ulcer of right elbow stage 4, venous insufficiency, hypothyroidism, hyperlipidemia, gastro esophageal reflux disease without esophagitis, chronic kidney disease stage 3, etc. Pressure ulcer list provided by the facility documented that R1 has 3 facility acquired pressure ulcers, stage 3 to the right elbow, stage 4 to the left leg and stage 4 to the sacrum. Wound note dated 11/5/2024 documented the following: stage 4 pressure wound sacrum full thickness, duration >2 days, wound size 8.0 x 15.5 x not measurable c. Depth is unmeasurable due to presence of nonviable tissue and necrosis. Hospital record dated 11/11/2024 documented in part, [AGE] year-old female presented from nursing home with pressure ulcer on the right elbow and worsening of sacral decubitus ulcer with foul smell draining pus. Same hospital records documented empiric treatment with IV (intravenous) Vancomycin and IV Zosyn, general surgery consulted, planning for surgical debridement. The record also documented that based on clinical assessment at admission, patient will require more than 2 medically necessary midnights of in-hospital care because of sacral decubitus ulcer infection. Infectious disease section of the hospital record documented that R1 will be de-escalated to Unasyn 3 grams every 8 hours to be continued at the nursing home for a total of 6 weeks. Minimum data set (MDS) assessment dated [DATE] section C (cognitive patterns) scored R1 as a 7 for brief interview for mental status (BIMS). Section GG (functional status) of the same assessment documented that R1 is dependent on staff for all activities of daily living (ADLS). Section H (bowel and bladder) documented that R1 is always incontinent of bowel and bladder. R1 has an order for weekly skin checks dated 8/30/2024, and there is no documentation of any skin checks in her medical record. 1/13/2025 at 9:40AM, R1 was observed in her bed, awake and alert and stated that she is doing okay. R1 said that she has not been changed today, she was last changed yesterday and feels like she is wet. R1 also said that no one has changed her wound dressing yet, she does not know who is her assigned certified nurse assistant (C.N.A) for today. At 9:46AM, V4 (C.N.A) was observed in the hallway and stated that she is assigned to R1, she has not changed R1 or her roommate yet, she was going to get them next after she finished with the resident she is helping right now. 1/13/2025 at 10:10AM, V4 (C.N.A) and V5 (restorative) were observed coming out of R1's room, holding a bag of dirty linen, V4 said that they just changed resident, her roommate is okay and does not need to be changed. Surveyor asked to see resident's dirty incontinence brief and noted a large area of reddish stain that saturated the brief. V4 stated that R1 was not wet, the stain is from her wounds. Surveyor asked to see resident's wounds and noted a large area of deep wound on resident's sacrum that looks red, with lots of drainage. V4 and V5 applied a clean incontinence brief on R1 with no dressing covering the wound and said that they will inform wound care nurse that resident's wound does not have any cover. 1/13/2025 at 1:05PM, R1 was observed still lying on her back and stated that no one has come to turn her or put a dressing on her wound. 1/13/2025 at 2:00PM, Observed wound care for R1 with V3 (DON) and V11 (Wound Tech). When V3 removed resident's incontinence brief, it was soaked with wound drainage and there was no dressing covering resident's wounds. Surveyor presented this observation to V3 and she said that she was not aware that R1 did not have any dressing to her wounds, no one informed her. She added that the wound should not be left without dressing because it will be losing hemostasis. 1/15/2025 at 11:58AM, V13 (LPN-Licensed Practical Nurse/Wound Care) said that she is familiar with R1 and has been treating her wounds since she was admitted to the facility. V13 said that she first became aware of resident's sacral wound on 11/4/2024, the wound team was just treating residents leg wound that was present on admission and were not aware of anything going on in resident's sacrum. V13 added that the wound care team did not do another skin assessment apart from the one done upon admission. As for the resident's order for weekly skin assessment, the floor nurses are supposed to do that in conjunction with the C.N.A's during ADL care and notify wound care of any skin alterations. V13 added that the facility dropped the ball this time, there was a gap in communication, resident's wound could have been identified earlier. Facility pressure injury prevention protocol (undated) stated in part: 1. Residents will be assessed to determine their risk factor(s) for pressure injury development, upon admission; weekly x 4 weeks following admission/readmission and at least quarterly thereafter. 4. Residents will have their skin checked and documented utilizing the Treatment Administration Record. This skin check will be performed at a minimum of weekly. Skin Assessment Policy and Procedure (undated) documented the following: Intact, healthy skin is the body's first line of defense. It is the policy of this facility to monitor the skin integrity for signs of injury and irritation. In addition to ongoing assessment of the skin, the facility will implement measures to protect the resident's skin integrity and to prevent skin breakdown. Upon admission to the facility the following will be assessed: (1) Risk for developing pressure injuries using valid assessment of pressure injury risk; (2) General skin condition; (3) Current injuries. Under procedures, the policy documented in part: All resident's, regardless of risk, will have a documented weekly review of skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to perform a safe transfer by not using the mechanical lift for 1 resident (R2) dependent on staff for transfers. This failure affected one of three residents reviewed for injury. This failure resulted in R2 sustaining an acute mildly displaced fracture of the distal femoral diaphysis on the left leg. This past non-compliance occurred from 11/7/24 to 12/4/24. The findings include: The facility reported to IDPH (Illinois Department of Public Health) that on 11/7/24 while R2 was being transferred to dialysis chair by CNA (Certified Nurses Assistant), R2 slid down and had an assisted fall. Shortly after, R2 complained of pain to left knee. Small bump noted to left knee. R2 sent to the hospital for evaluation. Imaging received from the hospital identified distal femur fracture. R2's diagnosis include but are not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 5 Chronic Kidney Disease, Atherosclerosis of Native Arteries of Left Leg with Ulceration of Other Part of Foot, Peripheral Vascular Disease, Anxiety Disorder, Depression, Polyneuropathy, Fracture of Lower End of Left Femur, Dependence on Renal Dialysis, and Weakness. Physical Therapy record includes diagnosis of Right Above the Knee Amputation. General Order dated 8/8/24 for R2 notes transfers: mechanical lift x 2 assist. On 12/12/24 at 12:00PM R2 said the day I fell I asked V9, Certified Nursing Assistant (CNA), for the mechanical lift and the dialysis chair. R2 said V9 said there was no time for that. R2 said V9 said I am not walking all the way down the hall to dialysis to get the chair. R2 said I fell as V9 and some other aid were transferring me into the chair in the dialysis room. R2 said I fell onto my knee, and it hurt. R2 said I told them I needed to go to the hospital. R2 said I went to the hospital, and I have a fracture. R2 said I did not get dialysis on that day. R2 said before the fall staff were not always using 2 people to transfer me. The surveyor observed R2 has left leg and old/healed right leg amputation. A lift pad was observed hanging on the back of R2's door. On 12/13/24 at 9:52AM V9 said I had taken care of R2 before. V9 said I got R2 ready, meaning I got her dressed for dialysis and gave patient care. V9 said I put a clean gown on her. V9 said I didn't have the proper stuff to work with R2 on that day. V9 said I got help from another CNA and put R2 in a wheelchair by lifting her in. V9 said we have done mechanical lift and manual lift transfers with R2. V9 said R2 don't stand at all, we have to completely lift R2. V9 said R2 didn't say anything about the transfer. V9 said this was not the first time R2 didn't have a lift pad in the room. V9 said if there is not a lift pad, then we are supposed to look for one. V9 said we couldn't find one. V9 said pads are hanging on the mechanical lift or they have they their own in the room. V9 said they (the facility) don't have a stock of pads. V9 said we took R2 to dialysis around 6:15-6:40AM. V9 said in the dialysis room as we were taking R2 out of the wheelchair she got twitching and wiggly. V9 said R2 was lowered to the floor. V9 said another aid helped me, I don't know her name. On 12/13/24 at 10:27AM V10, CNA, said a CNA was passing me by and asked me to help her. V10 said I didn't know R2. V10 said when we got to dialysis, I saw R2 had 1 leg. V10 said we tried to lift R2 into the chair and R2 could not hold herself up and we lowered R2 to the ground. V10 said in lowering her, R2 bent her leg. V10 said I never worked with R2 and didn't know she required a mechanical lift. On 12/12/24 at 1:14PM V2, Licensed Practical Nurse/LPN, said I wasn't there for R2's fall. V2 said I heard they needed help and came on the dialysis unit. V2 said I saw R2 was on the floor, she was crying out noises, sort of pain. V2 said we got her up and into a dialysis chair. V2 said R2 said she wanted to go to the hospital. V2 said R2's knee was visible. V2 said R2 expressed pain and according to the statement I looked and she may have had a bump. (The surveyor provided V2 with her witness statement during the interview.) On 12/13/24 V12, Restorative Nurse, said the staff have a sheet that tells them what level of assistance a resident requires. V12 said on admission I see the patient and identify the transfer status for them. V12 said on the care plan and resident profile sheet I include level of transfer assist needed for the resident. V12 said on hire I tell staff about the transfer status. V12 said R2 has been a mechanical lift since July 2024. V12 said on assessment R2 was weak and not able to use 2 person lift due to pain and shortness of breath. V12 said on 11/7/24 R2 was identified to require a full body mechanical lift. V12 said R2 usually has a lift pad hanging behind the door. V12 said when I spoke to R2 she said she asked the CNA to use the lift. V12 said the cause of the fall was that the staff did not use the lift to transfer R2. V12 said I have not received reports of lift pads or lifts not available for resident transfer. V12 said the lift pads are kept in the room behind the door, in the laundry room, and in my office. V12 said if I am not here the unit 3 nurse has the key to my office, so they can get a lift pad. V12 said R2 is alert. V12 said the practice to get a patient up for dialysis is to obtain the weight before getting out of mechanical lift. V12 said we have 3 full body mechanical lifts. V12 said the practice is to get the wheeled dialysis chair to the resident room, use the lift pad to transfer with the mechanical lift and place the residents into the dialysis chair and then bring the resident in the chair to the dialysis room. V12 said we usually don't place the resident into a regular wheelchair when preparing for dialysis. V12 said the staff needs to get the chair from dialysis. V12 said R2 did not have her prosthesis on the day of the fall, it is not even in the room. On 12/13/24 at 11:51AM V6, Assistant Director of Nursing, said I called the hospital to follow up on R2 and I was notified she had a fracture. V6 said R2 returned and she had the immobilizer on to her left leg. V6 said I started my investigation by asking R2 and the CNA what happened. R2 said while being transferred she slid and her left leg was unable to hold her body weight and she slid forward. V6 said the staff performed an improper transfer, R2 was supposed to be transferred with a mechanical lift. V6 said V9 transferred R2 with assistance from V15, CNA, from her bed into a wheelchair in her room. V9 then took R2 to dialysis room. V6 said then V9 attempted a second transfer to get R2 into the dialysis chair with assistance from V10. V6 said R2 was new to both V10 and V15. V6 said V9 performed two improper transfers with R2. V6 said the transfer procedure for R2 should have been to bring the dialysis chair to the room and then wheel R2 to dialysis in the chair. V6 said at dialysis the mechanical lift can be brought into the room and used to assist the resident into the chair. V6 said V9 said that R2 did not tell her that there was a lift pad in the room. V6 said V9 said she has gotten R2 up in the past without the use of the mechanical lift. V6 said R2 was working with therapy, but we had not gotten the ok from therapy to discontinue the mechanical lift. V6 said for the improper transfer I gave V9 disciplinary actions. V6 said V9 claimed there were no lift pads. V6 said each resident has 2 lift pads in the room, 1 for use and an extra one if soiled. V9 said if there is no lift pad, then the staff should look for another lift pad, if not found then they should notify the on call person that no lift pad can be found. V6 said I was not notified that they could not find a lift pad before the incident. V6 said R2 said she told V9 the pad was there. V6 was asked asked if the CNA should make the decision to not use a lift for transfers. V6 replied no. V6 said R2 has not had previous falls. V6 said R2 had an order in the old computer system (facility began a new electronic charting system in November 2024) stating she was a two person transfer with mechanical lift. V6 said the order was not discontinued. R2's MDS (Minimum Data Set) assessment for Cognitive Patterns assessment dated [DATE] notes a score of 15, intact. MDS Functional Ability assessment for R2 dated 10/21/24 documents impairments to range of motion to both sides of lower extremity. R2 is documented dependent on staff for toileting hygiene, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Dependent- helper does all of the effort. Resident does none of the effort to complete the activity. Functional Abilities assessment dated [DATE] identifies R2 is dependent for transfers. Restorative assessment dated [DATE] identifies R2 is dependent for transfers. R2 is non-weight bearing. R2 uses no splint, braces, or prostheses. R2's Fall Risk Assessment identifies R2 is at high risk for falls. Order Summary Report notes R2 has dialysis ordered Tuesday, Thursday, and Saturday. Incident occurred on 11/7/24, Thursday. Order Summary Report includes an order dated 11/13/24 for immobilizer to left knee at all times. R2's hospital record dated 11/7/24 CT of left knee findings states comminuted, mildly displaced fracture of the distal femoral diaphysis. Small knee joint effusion and mild surrounding soft tissue edema. X-ray of the left knee dated 11/7/24 states acute mildly displaced fracture of the distal femoral diaphysis. R2's hospital orthopedic consult dated 11/7/24 states she was being transferred to her dialysis chair and was accidentally dropped by a staff member, she reports her leg was bent back and was very painful. She complains of pain in the left knee, left ankle and has spasms going down her left leg. States she does not walk and has not walked in two years. She uses a mechanical lift for transfers and does not put weight through her left leg. Plan includes R2 is a poor surgical candidate due to bone quality and medical history. The facility did not provide a seperate incident/accident report than the facility IDPH reportable. The facility Limited Lift / Resident Handling policy dated 5/17 states It is the intention of this facility to provide safest environment as possible for our residents. Residents are assessed periodically for safety in transferring. Staff will use safety devices to assist in the transferring of our residents that have been assessed that the resident is no longer safe to be independent in this area. These devices may include gait belts and mechanical lifts. The facility Mechanical Lift policy dated 2/17 states A mechanical lift assist staff to lift and move a resident as safely and as easily as possible. Prior to the survey date of 12/18/24, the facility had taken the following action to correct the noncompliance: 1. Inservices for safer transfers began at the facility on 11/7/24-11/9/24. More inservices done 11/21/24 and 12/4/24. 2. Competency by return demonstration of safe transfer training. 3. Safe transfer audits are being completed, started 11/15/24; 11/16/24; 11/19; 11/25; 11/26; 12/3; 12/5 .and is ongoing during my survey. 4. QA meeting held 11/19 with administrator, DON, and medical director to discuss improvement plan. 5. Interviews with staff regarding transfer status knowledge. I have no concerns. 6. DON said there was 90% staff training completed on initial inservicing. As of Friday 12/13/24, there were 4 CNAs left to train. They are PRN (as needed) staff. 7. The CNA who performed the improper transfer had not returned to work because she refused to come to the facility for training. Observation of transfers during the survey completed, no concerns. Observation of mechanical lift pad equipment available to staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement and ensure effective interventions were in place to reduce the risk of falls/falls with injury for three of three residents (R58, R69 and R80) in the sample of 22 reviewed for fall prevention program. This failure resulted in R80 being sent to the local hospital sustaining a left femoral fracture. Findings include: On 6/26/2024 at 9:40am R80 was observed in bed with one floor mat on the right side of the bed only. On 6/26/2024 9:45am V13 (Licensed Practical Nurse-LPN) observed with surveyor R80 with one floor mat and said R80 is a high fall risk and should have two floor mats, one each side of the bed. On 6/26/2024 at 10:10am V2 (Director of Nursing-DON) said R80 is a high fall risk and should always have bilateral floor mats down while in bed. A face sheet indicated R80 was admitted to the facility on [DATE] and has a diagnosis of repeated falls, syncope and collapse. An initial fall risk assessment dated , 3/12/2024 had a score of 7 that indicated R80 was low risk. admission care-plan dated 3/13/2024 problem: History of falls. On 3/13/2024 a BIMS (Brief interview of Mental status) score was documented of 99-no resident was unable to complete interview. On 3/13/2024 a fall intervention was put in place, bed in a low position while in bed. On 3/17/2024 R80 had a fall, complained of hitting the back of his head and right wrist pain. An intervention of bilateral floor mats while in bed was put in place. On 3/23/2024 R80 had an unwitnessed fall and complained of left shoulder pain, an intervention of bed bolsters was put in place. On 4/5/2024 R80 was found on the floor with wheelchair turned over. No fall intervention was in place. On 4/14/2024 R80 had an unwitnessed fall, found lying on the floor next to his bed on his left side. R80 was unable to verbalize what happened. No fall intervention was put in place. On 4/14/2024 an x-ray of left humerus anatomic neck and multiple left ribs were observed. A portable x-ray dated on 4/26/2024 for pain and guarding, indicates R80 sustained a faint lucent line across the neck of the left femur, a subtle shortening of the femoral neck noted. Impression acute nondisplaced left intertrochanteric femur fracture. On 5/20/2024, most recent, R80 had a BIMS-score 99-no resident unable to complete interview. A physician order sheet dated 5/27/2024, no fall orders. On 5/29/2024 R80 had a fall, was observed on the floor in front of his wheelchair. R80 said he slid out of his wheelchair and was observed guarding his left lower extremity near his hip. No fall intervention was put in place. On 6/12/2024 R80 was observed on the floor in a laying position next to bed, could not verbalize what happened. A fall intervention was put in place for a safety appliance to elevate heel while in bed with a cushion. 2. On 6/26/24 at 10:48AM, With V14 Registered Nurse (Registered Nurse-RN) R69 was observed in bed in semi-Fowler's position leaning to the right side of the bed with her head hanging from the bed. V14 repositioned R69. R69 is alert and responsive but confused. No floor mat on the right side of the bed, only on the left side. R69's bed is not in the lowest position. V14 took the bed control on top of bedside drawer and placed R69's bed in the lowest position. V14 said that R69 is at high risk for falls. R69 should have a floor mat on both sides of the bed and the bed should be in the lowest position when in bed. V17 (Certified Nurse Assistant-CNA) said that she is the assigned CNA for R69. V17 said that she received R69 with only one floor mat on the left side of the bed when she came to work this morning. V17 said that R69 should have a floor mat on both sides of the bed and R69's bed should be in the lowest position. On 6/26/24 at 10:55AM, Informed V4 (Assistant Director of Nursing-ADON) of above observation. V4 said that R69 should have bilateral floor mats on each side of the bed and the bed should be in the lowest position while in bed. On 6/26/24 at 12:30PM, Informed V2 (DON) of above observation. V2 said that R69 is at risk for falls. She should have a floor mat on both sides of the bed and the bed should be in the lowest position while in bed. V2 added that they should implement fall preventive interventions in place. R69 is re-admitted on [DATE] with a diagnosis listed in part but not limited to repeated falls, history of falling, abnormalities of gait and mobility, unsteadiness of feet, muscle wasting and atrophy, osteoarthritis. Fall assessment done on 4/20/24 indicated she is at high risk for falls. Fall care plan indicated that she is at risk for falls related to impaired cognitive status, impaired functional status, weakness/deconditioning cellulitis of left lower limb. Intervention: Keep bed in lowest position with brakes locked. 3. On 6/26/24 at 11:56AM, R58 was observed with V10 (Concierge/CNA unit manager) lying in bed not in lowest position with only 1 floor mat on right side of the bed. V10 took the bed control located on top of his bedside drawer and placed R58's bed in the lowest position. V10 said that R58's should have bilateral floor mats on each side of the bed and bed should be in the lowest position when resident is in bed. On 6/26/24 at 12:30PM, Informed V2 (DON) of above observation. V2 said that R58 is at risk for falls and on a fall prevention program. He should have floor mats on both sides of the bed and the bed should be in the lowest position while in bed. V2 added that they should implement fall preventive interventions in place. R58 is re-admitted on [DATE] with diagnosis listed in part but not limited to history of falling, cognitive communication deficit, muscle weakness, osteoarthritis. Fall assessment done on 4/16/24 indicated he is at high risk for falls. R58's fall care plan indicates that he is at risk for falls related to difficulty with balance and gait, dependent on assistive device for locomotion, requires assist for toileting, use of medications that can cause weakness or lethargy, history of falls, and diagnosis including cardiac, vision impairment, incontinence, acute and chronic medication conditions. Interventions: Provide resident with safety device/appliance: Bilateral floor mats when in bed. Fall prevention program protocol. Keep bed in low position with brakes locked. Facility Policy: Fall Prevention and Management revised 2/2023 Purpose: The purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The falls prevention and management program are designed to assist staff in providing individualized, person-centered care. The falls prevention and management program provide a framework and tools to identify and communicate about a resident's risk for fall. Additionally, the program addresses a safe process to follow for supporting a resident who has experienced a fall event. Fall prevention Practices: Fall prevention and management practices include separate activities. . universal fall precautions Universal fall precaution: . universal fall precautions are safety measures that are taken to reduce the chance of falls for all residents regardless of individual fall risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R3 was diagnosed with generalized muscle weakness and osteoarthritis. Brief interview for mental status dated 05/09/24 documents a score of fourteen which indicated cognitively intact. Section GG (functional abilities) dated 10/28/23 documents: R3 needed partial/moderated assistance (helper does less than half the effort. Helper lifts, hold or support trunk or limb but provides less than half the effort) to roll left and right. On 5/21/24 at 2:33PM, V4 (Certified Nurses Assistant/CNA) said he was changing R3's linen (bed sheet/cover). R3's sheets were wet. R3's linen was half on the bed. V4 said, R3 was on his side but does not recall which side. R3 was not close to the edge. R3 was alert. R3 was able to help turn and reposition. V4 said, before he could walk around to the other side of R3's bed to complete making the bed. R3 fell face down on the floor. R3 sustained a cut above eyebrow which was bleeding. V4 said, he called V6 (Nurse). V6 assessed R3. V4 said, him and V6 got R3 off the floor using a bed sheet. 911 was called. R3 said he was not okay. On 5/21/24 at 2:49PM, V3 (Assistant Director of Nurses/ADON) said, R3 was alert and oriented times person, place and time. V4 was providing care for R3. R3 required one person physical assist for bed mobility. R3 had a bed support safety rail located on the right side of his bed. R3's right side was his strong side. R3 didn't grab the bed support safety rail when being turned. V4 pulled the draw sheet to assist with turning R3. R3 usually grabs the bed support safety rail to help with turning onto his side when requested. R3 rolled out of the bed onto the floor. R3 sustained a laceration to the left eye and knee. R3 was diagnosed with a subdural hematoma and left knee fracture. On 5/21/24 at 3:04PM, V3 said, the bed support safety rail is used to aide with bed mobility. Verbal cues were given to R3 to remind R3 to grab the bed support safety rail. R3 only needs prompting. V4 informed R3, that they were going to turn. R3 was awake but could have still been a little sleepy. V4 should have made sure R3 grabbed the bed support safety rail before proceeding to the next step of turning. On 5/21/24 at 3:10PM, V6 (Nurse) said, R3 was being changed by V4. R3 has a habit of not cooperating and being stiff. It might take a minute for R3 to relax his body. R3 may cooperate but on occasions additional staff is needed. V4 told R3 to turn on his side, which R3 can do with help. R3 was seen on the floor. R3 was on his left side facing his bed. R3 hit his forehead on the wheel of the bed. R3 complained of knee and back pain. R3 said he fell, he couldn't believe it and he was dazed. On 5/21/24 at 3:52PM, surveyor observed a bed support safety rail on the left upper side of R3's bed. R3 was assessed to be alert and oriented to person, place, and time. R3 said he was half asleep while being changed by V4. It was a routine activities of daily living (ADL) care. R3 said he was too close to the edge of the bed. R3 said, V4 pushed him to the right side resulting in a fall onto the floor. R3 said, at the time of the incident, he did not have a bed support safety rail on the right side. R3 said, he was holding the mattress. There was nothing else to hold on to. There were no floor mats on the floor. R3 said, his left side/left upper extremity was weaker than the right. R3 said, he did not have anything to assist him when he was turning on his right side. R3 said, V4 pushed him and he ended up on the floor. On 5/23/24 at 12:40PM, V17 (Physical Therapy Assistant) said R3 has a bed support safety rail on the left side of his bed. R3 did not have a bed support safety rail on the right. R3 has bilateral weakness to the upper extremities. A bed support safety rail is used for poor trunk control. It aides with turning right or left. R3's bed support safety rail on the left side can only assist with turning towards the left side. Nursing note dated 01/24/2024 documents: Writer called to resident room by CNA (V4) status post (s/p) witnessed fall, resident (R3) observed on floor, vitals performed, and neuro check performed. Resident assisted by two staff back to bed. Noted left brow bleeding, bruising and lacerations to left knee. 911 called. Facility fall occurrence dated 01/24/24 documents: General Information: Fall, Cognition prior to occurrence: oriented times two, Injuries: Laceration to left brow. Laceration and bruising to left knee. Notes: CNA was performing AM care and was rolling the resident to the side in order to change the bed sheets. When the CNA pulled the sheet to make the bed while resident was on his side, the resident rolled off the bed. Fall type: Falling to ground. Laying on right side, mattress on the floor: no. Facility final reportable incident dated 01/29/24 documents: V4 stated that he was providing ADL care to the resident (R3), during which he instructed the resident to turn to his right side. V4 states, that the resident has a bed support safety rail on the right side of his bed for mobility but did not grab it. V4 states that the resident turned with more force that normal and fell out of the bed at approximately 5:30AM. Hospital paperwork dated 1/24/24 document: Patient (R3) presented to the emergency department for evaluation of head injury after mechanical fall. Per emergency medical service (EMS), patient was turning in bed when he fell out of bed. Patient fell with head strike hitting the left portion of his forehead on the ground. Patient complained of left-sided knee pain (multiple abrasions noted to the left knee), left shoulder pain and pain associated with facial laceration to the left eyebrow (with bleeding) measuring four centimeters in length and depth requiring five sutures. CT (computed tomography scan) of the head demonstrated subarachnoid hemorrhage near the right frontal lobe. Left knee x-ray: Nondisplaced patella fracture. Patient placed in left-sided knee immobilizer. 3) R2 was diagnosed with Dementia with behavior disturbance, restlessness, agitation, weakness and generalized anxiety. Hospice referral package dated 2/19/24 documents: Family was looking for respite care 2/28/24 - 3/8/24. R2 has a history of falls. R2 has had three falls since admission. R2 needs standby assist with transfers. R2 continues to have progressive weakness. R2 does not ambulate at most times and the seat of the roller walker is used to move her about the home. On 5/22/24 at 12:34PM, V12 (Nurse) said, R2 had behavior issues. R2 attempted to get out of the chair and bed. Medications and distractions were not working. R2 would scoot to the end of her chair or sit sideways, putting legs over the chair arm and get out of the chair on her knees. R2 was able to move body and climb. On 5/22/24 at 1:50PM, V3 (ADON) said, R2 kept trying to get out bed on to the floor. R2 had a fall upon admission. The second incident was not a fall, R2 was on the floor in a praying position. R2 got herself out of the bed to pray. On 5/22/24 at 2:40PM, V45 (CNA) said, R2 was in a room away from the nursing station then she was moved across from the nursing station. Nursing note dated 2/28/24 documents: writer observed resident sitting on floor near bed. Nursing note dated 3/5/25 documents: resident (R2) climbed out of chair and sat on floor in a praying position. Fall report dated 2/28/24 documents: R2 was alert to self. BIMS (Brief Interview for Mental Status) 4 (severe cognitive impairment). Visually observed on the floor near bed, sitting on buttock. R2 demonstrated poor safety awareness and was unable to be redirected. R2 also had wandering behaviors with an unsteady gait. R2's fall care plan dated 2/28/24 documents: Resident has history of falling related to weakness, unsteady gait, and cognition. Interventions dated 2/28/24: Place resident in a fall prevention program; Provide resident an environment free of clutter; Keep call light in reach at all times. Intervention dated 3/29/24: Observe frequently and place in supervised area when out of bed. Falls prevention and management policy revised 2/2023 documents: The purpose of this policy is to suppose the prevention of fall by implementation of a preventive program that promotes the safety of residents based on care processed that represent the best way we currently know of preventing falls. The fall prevention and management program is designed to assist staff in providing individualized person-centered care. Fall refers to unintentionally coming to rest on the found, (sic) floor or other lower level. A fall without injury is still a fall. When a resident is found on the floor, a fall is considered to have occurred. Based on observation, interview, and record review the facility failed to ensure that coffee was served at a safe temperature below 140-degrees Fahrenheit (F), failed to ensure a resident was positioned safely while providing direct resident care, and failed to develop fall prevention interventions to include monitoring for a resident with a history of falls, severe cognitive deficits, dementia, and restless agitation. This failure affected 3 of 3 residents (R1, R3, R2) and resulted in R1 spilling coffee sustaining full thickness burns to the right posterior thigh measuring 13.9x6.3x0.1cm (centimeters) and to the left thigh measuring 4.8x18.5x0.1cm. This failure also resulted in R3 rolling out of the bed sustaining a laceration to left eyebrow, subarachnoid hemorrhage, and a nondisplaced patella (knee) fracture. Findings include: 1) R's latest admit date to the facility is 4/18/24 with a diagnosis of multiple sclerosis. Alzheimer's disease with late onset, major depressive disorder and anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents a brief interview for mental status score of 5/15 which indicates severe impairment. Under section GG functional abilities and goals under eating documents a score of five. Five indicates setup or clean-up assistance- Helper sets up or cleans up. Resident completes activity. Helper assists only prior to or following the activity. R1's physician progress note dated 1/18/24 documents: R1 is alert with periods of forgetfulness. She is able to follow simple commands but with frequent redirection and reorientation. Under psych exam: attention/concentration: attends to tasks with staff assistance, easily distracted; Judgement: impaired; insight: impaired; impulse control: impaired. Facility reportable dated 2/24/24 documents: R1 was in the dining room for breakfast and activities. After breakfast, R1 attended the activity taking place in the dining room. R1 requested for a cup of coffee from V5 (Activity aide). V5 said she placed a plastic coffee mug with coffee in front of R1 before returning to her tasks. R1 immediately grabbed the mug. Before staff could respond, she spilled the coffee on her lap. Under conclusion: Upon investigation the facility determined that the resident accidentally spilled coffee on herself. Staff responded immediately and provided first aide. Facility has reviewed and ensured all coffee machines are properly calibrated regarding temperatures. Staff was re-educated on assisting residents with hot items. On 5/22/24 at 10:48AM, V5 said she was preparing an activity in the common dining room when R1 requested coffee. V5 said she got coffee from the machine in the dining room and placed it in front of R1. V5 said she informed R1 the coffee was hot when she placed it on the table. V5 said she went on to continue the activity and heard R1 screaming out, It burns. V5 said she observed R1 with spilled coffee on R1 and the floor. V5 said R1 threw the coffee cup on the floor. V5 said R1 can be confused at times. V5 said after the incident she was told to let the coffee cool down before giving it to R1 or any residents. On 5/23/24 at 1:35PM, V9 (Nurse) was the assigned nurse to R1 on day of the incident. V9 said she did not witness incident but performed a skin assessment after the incident. V9 said R1's skin was red and blistering on both thighs. V9 said R1 is alert to self and has behaviors of throwing items when upset. V9 said she would not give R1 any hot liquids because of her behaviors of being impulsive and the possibility of injury occurring to R1 or other residents or staff. On 5/23/24 at 2:49PM, V20 (Nurse) said R1 is alert to self. R1 has behaviors of throwing things when upset and it is not a new behavior. V20 said she would not give R1 hot liquids due to this behavior. R1's progress notes dated 2/24/24 documents: Resident was observed in bed with redness and blistering to bilateral inner thighs. Writer was informed that resident was drinking coffee and spilled it on herself. PCP made aware, orders received and carried out. R1's wound doctor evaluation dated 2/27/24 documents: Patient spilled hot liquid on inner thighs. Under wound site one documents burn to the right posterior thigh full thickness measuring 13.9x6.3x0.1cm. Thirty percent of skin is fluid filled blister. Under wound site two documents: burn wound of the left thigh full thickness measuring 4.8x18.5x0.1cm On 5/22/24 at 9:56AM, V7 (Dietary Manager) said coffee should have a temperature of 130-140 degrees F when served. 140 degrees F would be the highest temperature because it may cause a burn. V7 said they check coffee temperatures weekly but do not have a log of the temperatures. On 5/28/24 at 1:31PM, V2 (Director of Nurses/DON) said R1 has a history of behaviors of throwing food and yelling out. V2 was asked how do staff determine who is safe to consume hot beverages. V2 said she was not able to answer that question. V2 said staff should wait a few minutes before serving any residents coffee. V2 was asked if the incident with R1 could have been avoided and V2 said probably not based on R1's impulsive behaviors, R1 would of spilled the coffee either way. Facility hot beverage policy dated 1/16 documents: Facility will ensure that residents are served hot beverages at a temperature that allows palatability while decreasing the risk of inadvertent burns. Hot beverages will include coffee. Dietary staff will take temperature of all hot beverages prior to each meal and record the results on the temperature log for coffee prior to service to resident. The logs will be maintained for one year by the food service supervisor. Those residents determined to be unsafe with hot beverages by the interdisciplinary team will be offered assistance when consuming hot beverages.

Based on observation, interview and record review, the facility failed to provide feeding assistance for residents with visual deficits that were identified as needing assistance which resulted in an unplanned serve weight loss. This affected two of three residents (R8, R9) reviewed for unplanned weight loss. This failure resulted in R8 having a weight loss of 8.99% in one month and R9 having a weight loss of 10.6% in four months. Findings Include: 1) R8 has a diagnosis with Dementia. On 05/24/24 at 12:21PM and 12:33PM, R8 was observed with her head tilted to the ceiling with a non-focusing blank stare while eating in the dining room with no feeding assistance. R8 was observed scooping pureed food off her plate onto the tray, putting the spoon in her mouth with no food on it. R8 dropped the spoon on the tray. R8 was observed tapping around on the tray with her hand, putting her fingers in food then licking food off her fingers for twelve minutes until she touched the spoon and preceded to feed self with small amounts of food. On 05/24/24 at 12:51PM, V3 (Assistant Director of Nurses) said, R8 required set up assistance only. R8 refuses help with feeding assistance. R8 has vision impairment. R8 was asked by the surveyor, if she would like some help with eating. R8 nodded head up and down in a yes motion. V3 said, R8 nodded head in a yes motion. V3 assisted feeding R8. R8 took two small portions of food from the tip of the spoon. On 5/24/24 at 2:30PM, V2 (Director of Nurses) said, R8 has had weight loss in last six months. V2 said, she expects staff to assist with feeding for R8 as recommended by the dietitian. Care plan dated 9/26/23 documents: R8 is alert with confusion and exhibits impaired cognitive functioning status. R8 is unable to visually track objects or people. Receive mechanically altered diet with puree meat and vegetables related to edentulous (no teeth): approach 1:1 feeding assist. R8's dietary note dated 05/08/2024 documents: weight: 79 pounds, down 9% and 10.9% x 1 and 6 months respectively. This is the lowest weight recorded over the past six months of reviewed data. Diet order dated 05/08/2024 documents: Patient (R8) must be fed by staff. Will need to continue to encourage by mouth intake at all meals. Recommendation: give much encouragement to eat. R8's vital report documents: May: 79 lbs (pounds), April: 86.8 lbs, March: 87.8 lbs, February: 84.6 lbs and January: 91 lbs. Facility weight maintenance policy revised 03/22 documents: It is the policy of this facility to monitor the nutritional status of all residents, including all the significant or trending patterns of weight change to maintain acceptable parameters of nutritional status. All significant, unplanned, or trending weight changes must be investigated by the facility. Suggested parameters for evaluating significance of unplanned and weight loss are: interval one month, significant loss of 5% or severe loss of greater than 5%; interval three months significant loss of 7.5% percent or severe loss of greater than 7.5%; interval six months significant loss of 10% percent or severe loss of greater than 10%. In the case of a significant weight or trending weight change the following steps will be taken; determine the possible cause; determine plan of action; notify the physician and responsible party. 2) R9 has a diagnosis of Dementia, Glaucoma, Intraocular Lens (tiny artificial lens for eye) and Multiple sclerosis. Brief interview for mental status dated 4/4/24 documents a score of fourteen which indicates cognitively intact. On 5/24/24 at 12:56PM, R9 was observed with a lunch tray on the bed side table directly in front of R9. R9 was trying to feed herself string beans with a spoon that she held backwards in her hand. R9 who was assessed to be alerted and oriented to person, place and time, said I can't feed myself. On 5/24/24 at 1:06PM and 1:15PM, While surveyors were observing R9's room, V34 (Guest Services-Certified Nurses Assistant/CNA) went into R9's room to assist with feeding R9. V34 said, she had never fed R9 before and she was just helping out. R9 said, V34 has never fed her before and she does not receive feeding assistance from any staff. V34 stop feeding R9. V34 said, R9 didn't eat much. On 5/24/24 at 1:50PM, V26 (Occupational Therapist/OT) said, R9 needs assistance with meals due to visual impairment and impaired coordination related to multiple sclerosis. V28 (OT) said, R9 was having difficulty getting food in her mouth. R9's coordination has gotten worst. On 5/24/24 at 2:30PM, V2 (DON) said, R9 is not on a weight loss program. Care plan edited 04/05/2024 documents: R9 requires assist with ADL's (activities of daily living) related to weakness, lack coordination and impaired mobility in regards to multiple sclerosis. Approach dated (7/7/2020) documents: R9 can eat in room and be monitored from hallway during rounds, (edited 1/11/24) documents: eating: supervision and set up help. R9's vital report dated 01/2024 - 05/2024 documents: May 179.8 pounds (lbs), April 186 lbs, March 187 lbs and January 198 lbs. Physician note dated 4/25/24 documents: R9 reports good appetite. Dietary note dated 5/8/24 documents: weight (WT): 180 pounds, down 11.2% x 6 months. Weight decline each month noted since 3/4. By mouth (po) intake does not appear to be meeting needs for weight maintenance. Some slow/steady weight decline may be beneficial as patient has a high body mass index (bmi) 29.9, however rapid loss is not desired. Facility weight maintenance policy revised 03/22 documents: It is the policy of this facility to monitor the nutritional status of all residents, including all the significant or trending patterns of weight change to maintain acceptable parameters of nutritional status. All significant, unplanned, or trending weight changes must be investigated by the facility. Suggested parameters for evaluating significance of unplanned and weight loss are: interval one month, significant loss of 5% or severe loss of greater than 5%; interval three months significant loss of 7.5% percent or severe loss of greater than 7.5%; interval six months significant loss of 10% percent or severe loss of greater than 10%. In the case of a significant weight or trending weight change the following steps will be taken; determine the possible cause; determine plan of action; notify the physician and responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow their policy in notifying a physician of a change in condition for one (R8) of five residents reviewed for change in condition notification in a sample of 17. This failure resulted in R8 being unresponsive, apneic with a faint pulse and expiring. Findings Include: On [DATE] at 3:15 PM, V8 (Registered Nurse) said that when she was doing her rounds between 5:30 AM and 6:00 AM she noticed that R8 was having labored breathing. V8 said that R8 was in bed #2. V8 left the room and went to the computer to check R8's code status. V8 said that the resident in bed #2 was listed as Do Not Resuscitate (DNR) which was supposed to be R9, but it was not R9 in bed #2, it was R8 in the bed. V8 said that originally, she called 911 because R8 was still breathing. V8 told the paramedics that R8 is a DNR upon the paramedics' arrival and the paramedics told V8 that they will work on R8 until R8's DNR paperwork is provided to them. When V8 provided the DNR form, the paramedics verified the name and then stopped the resuscitation. V8 said that she realized that the DNR was for R9 and not for R8. V8 said there was a mix up of beds between R8 and R9. V8 said that R8 did not have a wrist band and she had no other way to identify the resident other than what was in the computer. V8 was asked, how do you identify the residents? V8 response was Name, date of birth , Pictures, and social security number. V8 said that she called V2 (Director of Nursing/DON) and told V2 that R9 expired, but called back later and informed V2 that R8 was the person that expired and not R9. V8 said that V2 told her to call 911 and initiate cardiopulmonary resuscitation (CPR). V8 said that V8 did not provide any emergency care to R8 prior to calling V2. V8 said she did not notify the physician of the change in R8's condition. On [DATE] at 4:15 PM, V2 said that as a nurse, if a resident is having difficulty breathing, V2 would attend to that resident regardless of code status. On [DATE] at 2:00 PM, V2 said that staff are expected to administer any amount of oxygen to a resident in an emergency if the resident is showing signs of air hunger and notify the physician. On [DATE] at 10:40 AM, V14 (R8 Physician) said that R8 was a full code. V14 said that he was not on call on the day R8 expired. V14 said that V15 was covering for him. V14 said that if he was notified of the change in R8's condition, he most likely would have sent R8 out to the hospital for further evaluation. On [DATE] at 11:25 AM, V15 (Nurse Practitioner) said that V15 was on call on the day that R8 expired. V15 said that V8 did not notify V15 about R8's change in condition. V15 said that she would have absolutely sent R8 out to the hospital for evaluation depending on her condition. Facility Policy: Change in a Resident's Condition Status. Objective: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that oxygen was administered to a resident with labored breathing and failed to notify the physician of the change in condition for one of five residents (R8) reviewed for accommodation of needs in a total sample of 17. This failure resulted in R8 becoming unresponsive and apneic with a faint carotid pulse and expiring in the facility. Findings include: On [DATE] at 3:15 PM, V8 (Registered Nurse) said that when she was doing her rounds between 5:30 AM and 6:00 AM she noticed that R8 was having labored breathing. V8 said that R8 was in bed #2. V8 left the room and went to the computer to check R8's code status. V8 said that the resident in bed #2 was listed as Do Not Resuscitate (DNR) which was supposed to be R9, but it was not R9 in bed #2, it was R8 in the bed. V8 said that originally, she called 911 because R8 was still breathing. V8 told the paramedics that R8 is a DNR upon the paramedics' arrival and the paramedics told V8 that they will work on R8 until R8's DNR paperwork is provided to them. When V8 provided the DNR form, the paramedics verified the name and then stopped the resuscitation. V8 said that she realized that the DNR was for R9 and not for R8. V8 said there was a mix up of beds between R8 and R9. V8 said that R8 did not have a wrist band and she had no other way to identify the resident other than what was in the computer. V8 was asked, how do you identify the residents? V8 response was Name, date of birth , Pictures, and social security number. V8 said that she called V2 (Director of Nursing/DON) and told V2 that R9 expired, but called back later and informed V2 that R8 was the person that expired and not R9. V8 said that V2 told her to call 911 and initiate cardiopulmonary resuscitation (CPR). V8 said that V8 did not provide any emergency care to R8 prior to calling V2. V8 said she did not notify the physician of the change in R8's condition. On [DATE] at 4:15 PM, V2 said that as a nurse, if a resident is having difficulty breathing, V2 would attend to that resident regardless of code status. On [DATE] at 2:00 PM, V2 said that staff are expected to administer any amount of oxygen to a resident in an emergency if the resident is showing signs of air hunger and notify the physician. On [DATE] at 10:40 AM, V14 (R8's Physician) said that R8 was a full code. V14 said that he was not on call on the day R8 expired. V14 said that V15 was covering for him. V14 said that if he was notified of the change in R8's condition, most likely he would have sent R8 out to the hospital for further evaluation. On [DATE] at 11:25 AM, V15 (Nurse Practitioner) said that V15 was on call on the day that R8 expired. V15 said that V8 did not notify V15 about R8's change in condition. V15 said that she would have absolutely sent R8 out to the hospital for evaluation depending on her condition. Resident face sheet indicates that R8 was a [AGE] year old female, admitted on [DATE] with diagnosis not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (Primary, Admission), Dysphagia following cerebral infarction. Peripheral vascular disease, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, aphasia following cerebral infarction, and hypertension. [NAME] Fire Department Run Report dated [DATE] at 6:01:00 AM, had R9 name on this run report and documented that I/S was dispatched to a location for the 78 y/o female with difficulty breathing. U/A NH staff at door advised crew the pt. was breathing. Upon making pt. contact in pts. Room pts. Was found sitting up in the bed unresponsive and apneic with a faint carotid pulse. Pt. was placed supine in bed and airway was suctioned by NH staff and cleared of mucus. Pt. was ventilated with BVM. Patient became pulseless and CPR was initiated. Crew asked NH staff if the pt. had a valid DNR. NH staff advised that the pt., have a valid DNR and provided the crew with a paperwork which did not include pts. Valid DNR. Crew requested that NH staff locate and provide DNR for crew. CPR was continued by crew. Pt. placed on cardiac monitor with multi-use pads and rhythm check was performed. Pt. was asystole on cardiac monitor and CPR and ventilations were performed. NH staff came back to pt. room and handed crew a copy of the pts. DNR. Crew confirmed that the name on the provided paperwork from the NH staff and the DNR were for the same pt. and the DNR was valid. CPR was stopped by the crew for a rhythm check. Pt. was asystole on the monitor. (Local Hospital) was contacted via cell and pts. death was confirmed by (Doctor) at 0616 hrs. MPD officers were on Scene. Scene was turned over to MPD w/o incident. Medical Emergencies, Facility Policy: It is the policy of the facility to provide emergency care to a resident in need of it. Basic life support, including CPR will be provided until the arrival of Emergency Medical personnel in accordance with physician's order and a resident's Advance Directives. Emergency Care Procedure: M. Respiratory Distress, Treatment: 2. Check oxygen saturation. Administer oxygen when signs of air hunger are present. Medical Emergency Response Policy, Objective: 1. It is the policy of the facility to provide each resident with necessary emergency treatment. This includes the providing basic life support including CPR, to a resident requiring emergency care until the arrival of Emergency Medical personnel in accordance with physician's orders and resident's Advance Directives. Licensed personnel will assess the resident, determine interventions, notified the resident's physician, and document the event in the medical record. Change in a Resident's Condition or Status Policy, Objective: Our facility shall promptly notify the resident, his or her attending physician, and representative of change in the resident's condition and/or status. Procedures: 1. The nurse will notify the resident's attending physician or physician extender when: b) There is a significant change in the resident's physical, mental or psychosocial status.

Based on interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for 1 of 3 residents (R13) reviewed for safety, this deficiency resulted in R13 falling out of bed on 11/26/2023 and being sent to the local emergency hospital, sustaining an acute intraparenchymal hemorrhage. Findings include: On 12/8/2023 at 2:31pm V22 (Certified Nursing Assistant-CNA) said on 11/26/2023 between 4:00pm and 4:30pm she rounded and observed R13's head on the metal bar underneath the bedside table on the floor. V22 said that it looked like R13 hit her head on the metal bars of the wheels of the bedside table. V22 said that R13 did not have any floor mats at the bedside, and she is a high risk for falls. On 12/13/2023 at 3:45pm, V21(Registered Nurse-RN) said on 11/26/2023 at about 4:30pm, V22 notified her that R13 was on the floor and her head was lying on the metal part of the bedside table. V21 said R13 is a high risk for falls and assessed her and sent her to the hospital. On 12/14/2023 at 10:35am V2 (Director of Nursing-DON) said that as the fall coordinator if a resident is a high fall risk, she expects all fall interventions to be in place, there should have been fall mats at R13's bedside. R13's resident face sheet indicated that R13 has a diagnosis of Functional quadriplegia, hemiplegia and hemiparesis and cognitive functions. A care plan dated 11/24/2023 with a problem of history of falls and intervention approach to provide resident safety device, floor mats to bilateral sides of the bed. A fall incident report dated 11/26/2023 and a final report dated 11/27/2023 of R13 fall interventions, did not include bilateral fall mats being in place and the report also documents that R13 sustained an acute intraparenchymal hemorrhage. Facility Policy: Reviewed 2/2023 Falls Prevention and Management, Purpose: The purpose of this policy is to support the prevention of falls by implementation of preventive program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The falls prevention and management program are designed to assist staff in providing individualized, person-centered care. Fall prevention practices: Care planning and interventions to address fall risk factors: A fall risk care plan will be implemented as part of the baseline care plan to address universal fall precautions and as part of the comprehensive care plan utilizing information from the fall risk assessment. The care plan will be reviewed and revised as least quarterly and with any fall event the resident might experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the safety of a resident during a wheelchair transport for 1 of 3 residents (R2) reviewed for safety in the sample of 9. This failure resulted in R2's foot getting stuck under her wheelchair and causing a right tibial fracture (near her right knee) and experiencing subsequent leg pain. The findings include: R2's face sheet showed she was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include osteoarthritis of knee, osteoarthritis of hip, chronic pain, polyneuropathy, dementia, psychotic disturbance, anxiety disorder, chronic kidney disease, muscle wasting and atrophy, muscle weakness, and abnormal gait and mobility. R2's facility assessment dated [DATE] showed she had no cognitive deficits and required extensive assistance of staff for most cares. R2's 4/27/23 nursing note entered at 3:26 PM showed, Resident complained to POA (Power of Attorney) that she has pain in her vaginal area. POA made aware of resident's complaint. Writer assessed resident's complaint and made NP (nurse practitioner) aware, and NP ordered an x-ray of resident's right side from hip to foot . R2's 4/27/23 nursing note entered at 6:40 PM showed, X-ray completed and awaiting result. R2's 4/28/23 nursing note entered at 1:36 AM showed, Received x rays results acute non disclose fracture to right tibial . At 3:23 AM another nursing note was entered showing . order to send resident to [acute care hospital] . R2's 4/29/23 nursing note entered at 7:00 PM showed, Resident readmitted . Resident diagnoses: Right Fracture of Tibia Shaft (closed non surgery). Wearing immobilizer to leg. Patient will be non weight bearing . R2's eMAR (electronic Medication Administration Record) showed on 4/29/23 (readmission date to facility) R2 reported pain at a 10 out of 10 on the pain scale. R2's 5/19/23 nurse practitioner note showed, Patient is a [AGE] year old female with past medical history of dementia and hypertension is seen for follow up on her fracture . Patient has complaints noted to her right leg, but no numbness is noted. Continue present management with all medications continue Norco (narcotic pain medication) for pain management . Continue hinge brace to RLE (right lower extremity), circulation checks every shift . R2's 5/24/23 nurse practitioner visit note showed, . She is reporting right leg pain today, which has been present since her recent fracture . R2's acute care hospital paperwork showed she was admitted to the hospital on [DATE] for a fracture of her right tibial shaft and discharged back to the skilled nursing facility on 4/29/23. This same paperwork showed she was to be non weight bearing to the right lower extremity and was to wear a hinged knee brace . On 6/25/23 at 9:35 AM, R2 was lying in bed covered with a blanket. R2 said she was having pain to her feet and her right leg. R2 said she had injured her leg a little while back when someone was pushing her wheelchair in the hallway. R2 said, The girl told me to hold her papers. I had her papers on my legs and she was pushing my chair. The papers started to slide off my lap and when I tried to catch them because I told her I wouldn't let them fall. Part of my knee broke. I pulled my left foot up but didn't get my right one up, so it went up under the wheelchair . I had footrests before this happened, but they stayed in here (her room) all the time. Now they aren't allowed to take me out of the room without them. On 6/25/23 at 11:46 AM, V11 (Activity Aide) said, About a month ago R2 was at the nursing station when I asked her if she wanted to go to the activity. She did not have footrests on her wheelchair. I didn't really pay attention that she didn't have footrests. Her feet were up, and everything was good. It looked like she lost her balance, and she dropped her foot down. Her foot got caught up under her chair. I reported it to the nurse. [R2] said 'ouch my foot' so I had the nurse take a look at her. They tell us that if you see a patient that is pushing themselves, we should let them do it and if we push the resident in the wheelchair, we should have foot pedals. On 6/25/23 at 1:28 PM, V8 LPN (Licensed Practical Nurse) said R2 complains of pain to her right leg. V8 said usually therapy does an assessment and they determine if the resident needs foot pedals on their wheelchair. On 6/25/23 at 1:55 PM, V9 CNA (Certified Nursing Assistant) said the Restorative Aides determine if a resident needs foot pedals. V9 said the way the staff know what the residents needs are is by looking at the falling star that is posted on their door or they could ask the nurse. V9 said R2 can propel her wheelchair around her room with her arms now. V9 said if residents are being assisted in their wheelchair, they need to have foot pedals on. V9 said some residents propel themselves at times so they don't have foot pedals. V9 said if a resident propels their own wheelchair at times they would not have foot pedals on. On 6/25/23 at 2:30 PM, V2 DON (Director of Nursing) said R2 had worked with therapy on the day the incident occurred. V2 said when R2 was done in therapy they put her next to the nursing station in her wheelchair. V2 said R2 could propel her own wheelchair but she needed enough time to do it and it was difficult for her to maneuver the corners. V2 said V11 was going down the hall asking residents if they wanted to attend the activity. V2 said V11 got R2 straightened out in the hall so she could propel herself and then continued down the hall asking other residents if they wanted to go. V2 said when V11 came back down the hall she started pushing R2 around the corner. When she was pushing R2 her foot fell down and went up under the wheelchair. They had wheelchair pedals in the room but since therapy was working with her, they didn't have them on her chair. V2 said R2 does not necessarily need the foot pedals and she can tell you if she wants them. On 6/25/23 at 3:11 PM, V19 CNA said, Usually if the patient is in the wheelchair, they sometimes have footrests. We sometimes know what the resident needs from checking the care plan or asking the nurse. We are told we are supposed to have foot pedals on the chairs. We had an inservice about that. They said we can look on the back of the door or ask the nurse if the resident needs foot pedals. A policy addressing the use of foot pedals when transporting residents in wheelchairs was requested and not received.