Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to document accurate meal intakes, offer alternative meal options, and notify the physician or nurse practitioner of significant weight loss. Additionally, the facility failed to implement the dietitian ' s recommendations and follow the physician ' s orders to increase Remeron for weight management. This deficient practice affected two of the seven residents (R62 and R103) reviewed for nutrition and unplanned weight loss prevention. As a result, Resident R62 experienced a 10% unplanned weight loss over a six-month period. Findings include: On 4/8/25 at 12:10 PM, R62 was observed in dining room for lunch meal. Staff were observed setting up R62's tray. R62 was observed replacing the cover on plate and self propelling wheelchair out of dining room. On 4/8/25 at 12:15 PM, R62 was observed self propelling wheelchair into dining room. R62 lifted the cover over plate then replaced cover and left dining room. Staff were observed removing R62's tray and place on the cart for dirty plates. R62 did not consume meal. On 4/9/25 at 11:15 AM, V7 RD (registered dietitian) stated that V7 audits all resident weights each month. V7 stated that V7 will request a resident be re-weighed if there is a change in weight of 5 or more pounds in one month. V7 stated that residents with weight loss are monitored and discuss during morning meeting with the interdisciplinary team. On 4/10/25 at 1:00 PM, V15 LPN (licensed practical nurse) stated that the CNAs (certified nurse aides) document the amount eaten for each resident in their POC (point of care) charting. V15 stated that the CNAs will inform the nurse if the resident does not eat a meal. When questioned if V15 was aware that R62 did not eat lunch on 4/8, V15 did not respond. R62's POC charting, dated 4/8/25, does not note amount eaten for lunch was documented. R62's medical record does not note any documentation on 4/8/25 related to R62 not eating lunch. R62's POS (physician order sheet) notes an order for LCS (Low Concentrated Sweets) diet, Regular texture, Regular/Thin consistency. R62's weight documentation: On 4/9/25, R62's weight was 125 pounds On 3/10, R62's weight was 128 pounds On 1/8, R62's weight was 130.6 pounds On 10/4/24, R62's weight was 139 pounds R62's weight documentation notes 10.07% weight loss for 6 months. V7 RD (registered dietitian) note, dated 4/10/25, notes significant weight loss review. Current weight record for 4/9/25 recorded at 125 pounds. Weight over 1, 3, and 6 months are as follows: 1 month - 3/10/25 - 128(2.3%), 3 months - 1/8/25 - 130.6(4.3%), and 6 months - 10/4/24 - 139(10.1%). Significant weight loss at 6 months, which is unplanned/unavoidable and likely related to a combination of variable oral intake at mealtimes and behaviors associated with her diagnosis of dementia. Recommendations were to have a psychiatric consult placed as resident has the tendency to wheel herself around the unit throughout the day, and sometimes during mealtimes, in which case she may miss her meal. Nurse practitioner was also informed of recommendations. BMI (body mass index): 22.1 - underweight; desirable BMI for age >65: 23-29.9. Diet: Regular, LCS, thin liquids. Double portions and snack at lunch and dinner. Supplement(s): Supercereal at breakfast and Med Pass 120 ml (milliliters) three times daily. R62's medical record notes R62 was last seen by V7 on 12/4/24. This facility's weight maintenance policy, revised 03/2022, notes all significant, unplanned, or trending weight changes must be investigated by the facility. 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 the resident's nutritional status. R103 was admitted to the facility on [DATE] with a diagnosis of parkinsonism, dementia, and contractures. R103 progress notes dated 1/15/25: Registered Dietician follow up. Resident's weight has trended down x past 6 months, in which weight history and current nutritional interventions were discussed with Nurse Practitioner. Resident is receiving Super cereal at breakfast, Health Shake q meal, Pro-Stat Sugar Free 30 ml every day and Remeron 7.5 mg at bedtime, thus Nurse Practitioner was agreeable to increasing dose of Remeron to 15 mg q HS. R103's nurse practitioner progress notes dated 1/17/25: patient seen and examined. Reason for visit: Weight loss. dietician following discussed with dietician will increase Remeron to 15mg continue all interventions per dietician. On 4/10/25 at 10:29AM, V12 (Nurse practitioner) said she would expect her orders to be followed as ordered. V12 said any new orders are verbally relied to the nurse to put into the electronic computer system. V12 said Remeron would be ordered to help increase a resident's appetite with weight loss. On 4/9/25 at 11:13AM, V7(dietician) said he expects his recommendations to be followed unless the physician does not agree. V7 said he recalls speaking to the V12 (nurse practitioner) about increasing Remeron due to weight loss for R103. V7 said R103 body max index was 14.3 which is considered underweight. R103's current physician order documents. Remeron 15 mg. Give 0.5 tablet (7.5MG) orally at bedtime with a start date of 10/24/24. R103's medication administration record for January, February. March and April documents: Remeron 15 mg. Give 0.5 tablet (7.5MG) orally at bedtime. Facility policy physician orders revised 5/2017 documents: all residents medications, and treatments must be ordered by a licensed physician or nurse practitioner. Physician orders must be reviewed every 60 days. The nursing staff member who took the order or the one assigned to the resident is responsible to transcribe the order. On monthly basis, the physician orders will be reviewed for accuracy by nursing personal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively supervise and ensure one resident was seated properly in wheelchair with feet on footrests or elevated off floor prior to transporting. This affected one of three residents' (R1) reviewed for safety. This failure resulted in R1 falling from the wheelchair sustaining a laceration to forehead requiring seven sutures and a left patella fracture. Findings include: On 10/12/24 from 11:20 AM until 12:40 PM R1 was observed sitting in wheelchair in the dining room. R1 was observed sitting with back against wheelchair back and holding a doll. R1 was able to feed self once her meal was set up for her. R1 was not observed shifting weight, leaning forward in wheelchair, or making any sudden movements. On 10/12/24 at 12:40 PM, V3 CNA (certified nurse aide) was observed transporting R1 to R1's room. R1's room is directly across from the nurses' station. V3 and V4 CNA were observed transferring R1 from wheelchair to bed. R1's wheelchair was placed next to bed. V4 placed a gait belt around R1's waist and drag pivoted R1 onto her bed. R1's legs were bent at the knees throughout transfer. R1 was not able to straighten legs to support R1's weight. R1's upper body was observed leaning far forward. R1 was totally dependent on V3 and V4 for transfer. R1's care plan, initiated 5/1/2015, notes R1 has risk or actual needs/symptoms related to Alzheimer's disease and dementia. Interventions include provide reminders for ADL (activities of daily living) and provide cues and supervision for ADLs every day. R1 falls care plan, initiated 5/1/2015, notes R1 is at high risk for falling related to decreased bed mobility and ambulation, Alzheimer's disease, dementia, muscle weakness, difficulty in walking, and multiple comorbidities. R1's falls risk assessment, dated 7/16/24, notes R1 is at high risk for falls. R1's OT (occupational therapy) evaluation, dated 6/25/24 notes R1 dependent for upper body dressing, transfers, and unable to stand and bear weight. R1's OT Discharge summary, dated [DATE], notes R1 requires substantial/maximum assistance with upper body dressing. R1 requires substantial/maximum assistance with transfers from bed to wheelchair to bed. R1 is able to stand for 30 seconds with maximum assistance of two persons. R1 achieved maximum potential with OT and was discharged from skilled therapy. R1's MDS (minimum data set), dated 7/16/24, notes R1 with functional limitation in range of motion in both upper extremities. R1's cognitive status for daily decision making is severely impaired. R1's ADL care plan, initiated 8/6/2019, notes R1 is at risk for ADL decline related to generalized weakness and deconditioning. Interventions include transfers - R1 is dependent on staff for all transfers, use mechanical lift device for all transfers. Wheelchair - R1 requires substantial/maximum assistance for locomotion. R1 may require two person assist in periods of lethargy, weakness. On 10/12/24 at 12:40 PM, V3 CNA (certified nurse aide) stated prior to R1's fall, R1 was able to self-propel in wheelchair. V3 denied witnessing R1 lean forward in wheelchair or attempt to stand unassisted by staff. On 10/12/24 at 12:45 PM, V4 CNA stated prior to R1's fall, R1 was able to self-propel in wheelchair. V4 denied witnessing R1 lean forward in wheelchair or attempt to stand unassisted by staff. V4 stated prior to fall R1 was able to take a few steps with staff assistance. On 10/13/24 at 4:15 PM, V5 LPN (licensed practical nurse) stated on 8/17/24, V5 was in the resident room next door to R1's room. V5 stated when V5 exited room V5 observed R1 on the floor. V5 stated V6 CNA informed her R1 leaned forward and fell out of wheelchair. V5 stated R1 was able to stand while sitting in wheelchair but would sit right back down. V5 stated R1 was able to self-propel in wheelchair prior to the fall. On 10/14/24 at 12:13 PM, V9 CNA stated she was working on 8/17/24 evening shift when R1 fell. V9 stated prior to the event she was sitting at nurses' station charting on computer. V9 stated R1 is a two person transfer and she instructed V6 to let her know when she was ready to have her assist with transferring R1 to bed. V9 stated V6 CNA stated, okay R1 lets go. V9 stated she did not hear V6 call out to R1 after this. V9 stated no other words were spoken prior to the fall. V9 stated she then heard a boom and looked up to find R1 lying on the floor on side in a fetal position; R1's legs are semi contracted. R1's medical record, dated 8/17/24 at 7:08pm, V5 LPN (licensed practical nurse) noted after eating dinner, R1 was being taken to bed by V6 CNA in wheelchair upon which R1 leaned forward in wheelchair and fell forward, face down to the floor. Upon assessment R1 received moderate sized abrasion to middle of forehead with moderate blood present. R1 remains alert, and verbal during occurrence. Neurological check initiated: no deficits noted. No indication of pain or discomfort. No vomiting or loss of consciousness observed. Pupils equal and reactive to light. Level of consciousness and range of motion to all four extremities at baseline. R1's vital signs stable. EMS (emergency medical services) 911 called and arrived within 5 minutes of occurrence. R1 transported to the hospital for further evaluation. On 8/18, the emergency room nurse said R1 had CT (computerized tomography) scan of the head, cervical spine, facial bones, and all are negative. R1 received seven sutures to laceration on forehead. On 8/22 at 11:00am, V7 LPN noted V7 was notified by therapy upon R1 assessment, R1 grimacing and pointing fingers to the left knee. Upon assessment V7 noted R1's left knee swollen, light redness, warm to touch, skin intact. On pain scale, R1's pain is 6 out of 10. Acetaminophen administered. V8 NP (nurse practitioner) informed with order to send R1 back to the hospital to repeat CT scan, radiology due to R1's recent fall. On 8/22, V8 NP noted laceration of mid forehead with seven sutures, discoloration of right and left eyes, and discoloration of chin. Left knee redness and swelling, limited range of motion. 8/22 at 3:56pm, R1 returned to facility with diagnosis of non-displaced transverse fracture of left patella- brace (knee immobilizer) applied in the emergency room with order to follow up with orthopedic surgeon. This facility's investigation into R1's fall notes R1 is cognitively impaired, with memory and recall problems. R1 communicates primarily in Polish. Per V6 CNA, R1 looked tired, V6 went to R1, unlocked brakes on wheelchair and was preparing to wheel R1 to room when R1 suddenly leaned forward resulting in R1 falling from wheelchair. V6 is no longer employed at this facility and was unable to be interviewed during this survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have effective interventions in place to keep a resident free from fall related injury for a resident with a history of falls. This failure applied to one (R6) of one resident reviewed for accidents and supervision and resulted in R6 experiencing four falls in four months and sustaining a laceration to the head requiring three staples and a subdural hematoma. Findings include: R6 is an [AGE] year-old male who has multiple diagnoses including but not limited to the following: difficulty in walking, altered mental status, need for assistance with personal care, muscle weakness, frontotemporal neurocognitive disorder, unsteadiness on feet, abnormalities of gait and mobility, failure to thrive, and dementia. Per fall report and progress notes for R6 dated 7/8/23, shows resident had an unwitnessed fall while ambulating in his room. R6 was noted to have a laceration to the back of the head and was sent to the hospital where he returned to the facility with three staples. Per fall report, no recommendations were made. Per plan of care, resident did receive a bed alarm that was later discontinued on 8/14/23 and reinstated on 9/8/23. Per fall report and progress notes for R6 dated 8/10/23, shows resident had a witnessed fall while ambulating in room. R6 was seen ambulating with shoes that were bigger than his feet. R6 fell backward in room and hit back of his head. R6's closet was assessed to ensure shoes fit, plan to ensure resident is wearing proper footwear, and roommate's shoes were moved out of reach. Per fall report and progress notes for R6 dated 9/25/23, shows resident had an unwitnessed fall and was found on the floor next to the bed. Interventions were to provide toileting assistance prior to going to bed and a medication review was completed. Per fall report and progress noted for R6 dated 10/1/23, show resident had an unwitnessed fall while ambulating in his room. R6 was found in room behind door, laying on his left side with bed sheet wrapped around lower extremity. R6 was sent to the hospital where he sustained a subdural hematoma and was later admitted to inpatient hospice. On 10/25/23 at 12:16PM, V5 (Licensed Practical Nurse) was interviewed regarding R6. V5 said I took care of R6 many times. R6 had dementia and got very confused later in the day. R6 was noncompliant with care and needed a lot of redirection. R6 would do things like put two legs in one leg pant, put items down his pants, rummage through his closet, etc. V5 said R6 was constantly getting up without asking for assistance. R6 had advanced dementia and could not use the call light. R6 needed one on one supervision but we do not provide this at the facility. V5 said, We would try and have a staff member with him at all times, but that is not something we could sustain. His (R6's) room was not close to the nursing station but was closer to the dining room. I know he had falls but I do not remember specifics. Per R6's fall reports, V5 was the nurse on 8/10/23 and 9/25/23, however V5 could not provide this surveyor with any details on the falls. It is to be noted that resident (R6) resided in a room on the other side of the unit, not visible or in close proximity to the nursing station. On 10/23/23 at 12:19PM, V17 (Restorative Director) was interviewed regarding the fall prevention program within the facility. V17 said, (V18 - Assistant Director of Nursing) and me are responsible to complete the fall reports. (V18) lets me know what interventions will be put in place and I add them to the reports and care plans. Some interventions that we utilize in the facility are low beds, floor mats, bolsters that are built into the mattress, anti-slide wheelchair device, anti-roll back brakes, etc. On 10/25/23 at 10:45AM, V2 (Director of Nursing) was interviewed regarding R6. V2 said, I am not familiar with his (R6) falls as I started here in August. I did know (R6) was confused, impulsive, and unaware of his safety. This surveyor requested names of staff members that could provide information regarding R6 and his falls. V2 directed this surveyor to interview V18 (Assistant Director of Nursing). At 11:45AM, this surveyor attempted to interview V18 regarding R6 and his falls. However, V18 said she was not familiar with R6 and could not provide much information about his falls. On 10/24/23, all fall reports for R6 from July 2023-October 2023 were requested from both V1 (Administrator) and V2 (Director of Nursing). Fall reports for 7/8/2023, 9/25/23, and 10/1/2023 were received. The fall list reported falls for R6 on 7/8/2023, 9/25/23, and 10/1/2023. Progress notes dated 8/10/23 showed R6 sustained a fall. Requested fall report for 8/10/23 from V1 and V2 on multiple occasions on 10/25/23. This surveyor was provided a document without R6's name present and brought concern up to V1. Later, this surveyor was given a fall report from 8/10/23. It is to be noted the fall on 8/10/23 was not listed on the fall list and was not initially given to this surveyor with the requested documents. It is also to be noted that this surveyor received fall reports and care plans on 10/26/23, two days after they were requested that did not match the original documents received. It is also to be noted that some of the interventions listed on the original care plan received were not part of the new care plan received on 10/26/23. Facility policy titled Falls Prevention and Management with reviewed dated of 2/2023 states in part but not limited to the following: The purpose of this policy is to support the prevention of falls by implementation of a preventative program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. Development of the fall risk care plan is based on results of the falls assessment as well as investigation of all circumstances and related resident outcomes. The care plan addresses universal fall precautions and individual fall risk factors as applies to the resident. Staff shall maintain communication with appropriate personnel when situations or residents behavior suggest that the current interventions are not effective. The facility shall re-evaluate as needed to promote safety.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop effective interventions to prevent or reduce the risk of falling for a resident with dementia, unsteady gait, poor safety awareness, and high risk for falls. This failure affected 1 of 3 residents (R2) reviewed for fall prevention. These failures resulted in R2 being involved in a fall incident casing pain to the left hip area. R2 was sent to the local hospital and evaluated and treated for a left hip fracture. Findings include: R2 face sheet shows R2 is [AGE] year-old female with diagnosis of dementia, anxiety disorder, psychosis, chronic kidney disease, hyperlipidemia, dysphagia, unsteadiness on feet, abnormal weight loss, altered mental status, history of acute respiratory disease, hypertension. On 2/6/23 at 12:50PM V18 (R2 family) said she doesn't feel like the facility put adequate fall interventions in place for R2. V18 said R2 fell in November and sustained a hematoma and bruise to her head. V18 said V19 (Nurse) informed her that R2's bed alarm was not in place on 12/19/22 when R2 fell. V18 said she had questions why the nurse didn't hear R2's alarm sounding but instead heard R2 yelling for help. V18 said she voiced this concern with the facility and she (V18) was told that R2 fiddled with the alarm and it was not on. V18 said R2 fell in the dining room on 12/27 and she wonder how it happened. V18 said she has concerns about R2's falls at the facility. V18 said R2 sustained a hip fracture and had surgery and R2 has since passed away. V19 was called on 2/6/23, message text and voice mail left for V19. However, V19 did not return call to surveyor during this survey. R2 MDS dated [DATE] section C denotes 1 for short term memory problems, 1 for long term memory problems, cognitive skill for daily decisions making 3 for severely impaired. Inattention (difficulty focusing attention) is noted at 2 (behavior present, fluctuates). Disorganized thinking (rambling or irrelevant conversation, unclear or illogical ideas or unpredictable switching from subject to subject) 2 is noted 2 (behavior present, fluctuates). Section G for activities of daily living denotes R2 requires extensive assist and 1-person physical assist with bed mobility. Transfer shows R2 requires extensive assist and 1-person physical assist with transfers. R2 fall report dated 11/18/22 denotes in part, R2 observed on the floor post fall. R2 unable to verbalize what happened that led to fall d/t diagnosis of dementia. R2 is in temporary new environment d/t COVID-19 status and unable to acclimate easily to environment d/t dementia. R2 transferred to hospital for further medical evaluation. CT negative for major injury. R2 to continue skilled therapies, bed alarm provided at this time. On 2/5/23 at 11:20am V5 (Restorative nurse/ falls nurse) said R2's fall was due to R2 being in a new surrounding due to room being temporary changed. V5 said the intervention was to put a bed alarm in place. R2 fall report dated 12/19/22 denotes in-part fall, time 1:50am, resident room, sleeping or lying in bed, witness-none. R2 observed on the floor post fall. R2 observed sitting on the floor, arms on each side, legs positioned straight. R2 unable to verbalize what happened that led to fall. R2 is noted sitting on folding chair brought by family, chair observed folded. Chair removed from room. Family educated in regards extra furniture in. Family verbalized understanding. Fall precautions remain in place and working condition. Staff to continue to monitor and redirect R2 as needed. On 2/5/23 at 11:20 am V5 (restorative nurse/ falls nurse) said the intervention was to remove the clutter from R2 room (regarding 12/19/22 fall). V5 said she don't know what R2 was trying to do. V5 doesn't know why R2 was out of the bed at 1:50 am (on 12/19/22). R2 fall risk dated 12/19/22 denotes in-part R2 is high fall risk (score 15), has intermittent confusion, balance problems with walking, requires use of assistive devices, R2 is up adlib, assistance to/from toilet, use antihypertensive, R2 had 1-2 falls in last 3 months, decline in functional status, referrals to fall program, continue current care plan. R2 fall investigation dated 12/27/22 denotes in-part, fall, dining room, ambulating, witness-none. Injuries- right eyebrow. R (right) forehead noted with raised discoloration area. R2 observed on the floor in dining room post fall. Per R2, she wanted to get some water. Head to toe assessment done, no injuries sustained. R2 transferred to her room, fluids offered. R2 referred to NP post fall, referred to neurologist MD (Medical Doctor) D/T (due/to) increased falls. Fall precautions remain in place and in working conditions. Staff to continue to monitor and redirect R2 as needed. Recommendations- none noted. On 2/5/23 at 11:20am V5 (restorative nurse/ falls nurse) said the intervention was to refer R2 to the neurologist (regarding 12/27/22 fall). V5 said R2 had not seen the neurologist by date of discharge on [DATE]. V5 said the water cooler was about 10 feet from R2 wheelchair. V5 was asked if the dining room floor was wet when R2 slipped and fell. V5 said she didn't know; she would have to ask the nurse that was on duty. V5 said she completed the investigation for this fall. V5 said she did not ask the nurse if the floor was wet when R2 fell. V5 said staff was in the dining room passing dinner trays. V5 was asked why staff in the dining room didn't redirect R2 immediately when R2 got up from the wheelchair. V5 respond that, We do our best to monitor. V5 was asked if there were new interventions put in place after the fall on 12/27/22. V5 said the neuro consult. Review of R2 most current POS (physician order sheet) there are no orders noted for a neurologist consult noted. R2 progress note dated 12/31/22 while passing medications in the dining room, writer heard sound of bed alarm coming from resident's room (R2's room), immediately went to resident's room accompanied by another RN. Walked into the resident's room, observed resident lying on the floor next to her bed on left lateral side. Un-witnessed fall, resident was immediately immobilized on the floor in order to perform head to toe assessment. Assessed resident for pain, patient denied any pain. Resident A/O x 1 on and off, confused in her base line mental status. DX: Unspecified dementia with behavioral disturbance. V/S checked BP: 151/73 P:98/MIN SPO2: 97% RA T: 98.2 F tympanic R:19/min. Writer asked the resident what happened, resident unable remember and verbalize due to dementia cognitive. Resident was asked if she hit her head, resident verbalized No, I did not hit my head, only my left elbow. Resident denied any pain. Resident did not complain of any headache, nausea, or dizziness. Writer immediately performed head to toe assessment with another nurse, head, and neck intact, no redness, no discolorations or swelling observed. Writer observed small superficial skin tear on left elbow, no swelling, and no redness no S/S of infection at the area, first aid provided tolerated well. Resident is able to move her head and neck without any limitations or pain. Eyes checked: PERRLA. Resident is able to move her upper and lower extremities without any limitations, no Rotation/Deformity/Shortening noted. Hand Grasp: Equal in upper extremities. Neurological assessment initiated due to un-witnessed fall/ in resident's baseline. After the assessment resident was placed safely on her bed. Bed at lowest position, call light within reach, bed alarm on all the time. Nursing supervisor/ POA/MD made aware. R2 fall investigation dated 12/31/22 denotes fall, activity- sitting, witness- none. Injuries none noted. Immediate action neuro checks initiated, placed in wheelchair, 1:1 supervision implemented, ROM (range of motion) W/I (within) normal limits for residents, POA notified of occurrence, resident care card updated, assess for pain, encourage resident to ask for assistance before standing, referred to PT, placed in bed, head to toe body check, notified immediate supervisor, CNA assigned updated, refer to other physician, neuro assessment, MD notified, refer to OT. Conclusion written by V5 (restorative nurse) entered on 2/4/23 at 12:34 pm R2 observed on the floor next to her bed post fall. R2 unable to verbalize to staff what happened that led to fall D/T Dx (diagnosis) of dementia. R2 denied pain or discomfort post fall. First aide provided to left elbow by NOD (nurse on duty). Staff to continue to remind R2 not ambulate/ transfer without staff assistance. R2 referred to skill therapies post fall. R2 has fall preventions measures in place and in working condition. Staff to continue to monitor and redirect. On 2/4/23 at 4:10 p.m. V7 said on 12/31/22 she was near the dining room when she heard a bed alarm and as she went to see where the alarm as coming from, she noticed R2 laying on the floor near her bed. V7 said R2 had an abrasion to the left elbow and first aid was rendered. V7 said she completed an assessment along with the other nurse. R2's range of motion to the upper and lower extremity was within normal range for R2. V7 said R2 denied pain and could not say what happen. V7 said she had just walked past R2 room and saw R2 sitting on her bed. V7 said her, another nurse and V6 all got R2 up and placed R2 in the wheelchair and escorted R2 to the dining room. V7 said R2 has dementia and has poor safety awareness. V7 omitted going into R2 room to determine if R2 needed something and or to determine why was R2 sitting at R2's bedside just prior to the fall. V7 was asked what R2's behavioral disturbance was. V7 said she did not know about R2 having a behavioral disturbance. On 2/5/23 at 11:20 am V5 (restorative nurse/ falls nurse) said the intervention was to give R2 verbal reminders not to ambulate without assistant. V5 said this is done if the staff sees R2 trying to get up from the bed. V5 was asked if the staff was doing that already. V5 responded, I care planned that on 1/2/23. V5 said R2 was referred to physical therapy also. V5 was asked what was R2 trying to do when R2 fell. V5 said R2 could not say because R2 has dementia. V5 was asked if the nurse should have gone in to R2's room see if she needed anything when she saw R2 sitting at the bed side. V5 responded, Yeah if she saw (R2) trying to get up, but she didn't know if R2 was trying to get up. V5 was asked if it's reasonable to believe that one must come to a sitting positing before getting up from bed, and that could be an indicator that a person may be trying to get up if they're sitting on the bed. V5 said R2 would usually sit in her chair at the bedside, so she would not think R2 was trying to get up from bed. V5 said she doesn't know what R2 was trying to do. V5 said R2 has dementia and poor safety awareness. V5 said R2's room is in a high traffic area so R2 can be monitored by staff as they walk pass or are sitting at the nurse station. V5 was asked how was R2 being monitored. V5 said staff should check on R2 frequently, redirect R2 if R2 is trying to get out of bed, toilet R2 as needed, provide water if R2 needed it. V5 said R2 was put on 1:1 monitoring after the fall on 12/31/22. V5 said she conducts the fall investigation at the facility and the root cause of the fall and interventions are developed with the interdisciplinary team. V5 said the facility does not have a fall prevention program. They use universal fall precautions. V5 said the fall interventions should be developed and implemented based on the root cause of the fall. V7 (Nurse) omitted putting R2 on 1 to 1 monitoring after the fall on 12/31/22. V7 said R2 was put in the wheelchair and taken to the dining room with the other residents. On 2/6/23 at 2:13pm V9 (ADON) said all falls should be thoroughly investigated. V9 said the falls are reviewed in the daily morning meetings. V9 said the falls interventions are developed with the interdisciplinary team. V9 said, we don't know what R2 was trying to before she was observed on the floor on 12/31/23. V9 said it is not uncommon for R2 to be sitting at the bedside because that's what R2 used to do before she started having falls. V9 said R2 had COVID-19 infection and was weaker. V9 was asked if R2 was weaker according to what she just said, would it be reasonable to believe R2 could fall if she is observed sitting at the bedside alone, has poor safety awareness, needs one-person physical assist with bed mobility, and recently had a fall from the bed and is a high fall risk. V9 said she would expect the nurse to go in R2 room if she saw R2 at sitting at the bedside to redirect R2. V9 said R2 needs one-person assist with bed mobility and transfer. Review of R2's current POS shows there were no orders noted to limit R2's movement or keep R2 in the bed until R2 gets the left hip X-ray completed. V10 (CNA) said R2 was up in the wheel chair for her shift (3-11pm) on 1/4/23. R2 Xray dated 1/4/23 shows in-part R2 had the alignment is normal, acute left femoral neck fracture. The joint appears well maintained. The soft tissue is unremarkable. R2 progress note dated 1/5/23 denotes in-part on call Doctor called and ordered the patient to be sent to ER (emergency room) for evaluation. On 2/5/23 at 11:20am V5 said that fall risk assessment is not accurate because R2 should not be up at liberty, R2 requires monitoring. V5 said the fall risk assessment should be completed accurately because that information is used to developed plan of care for fall intervention. R2 fall risk assessment dated [DATE] denotes a fall score of 22 (high risk). R2's care plan shows problem start date 2/3/2020. R2 is at risk for falling R/T poor safety awareness, d/t Dementia Dx (diagnosis), Anxiety, and Unsteadiness on feet. R2 is non-compliant with fall prevention measures. R2 will remain free from injury r/t (related to) fall target date 2/28/23. Xray of Left hip/femur/ thigh ordered d/t complaints of pain post fall. R2 referred to skilled therapies post fall. Give R2 verbal reminders not to ambulate/transfer without assistance. Neuro consult d/t recent falls. R2 referred to NP post fall. Provide R2 an environment free of clutter. Provide R2 with safety device/appliance: bed alarm. Transfer R2 to RMC ER for further medical evaluation post fall. Assure R2 wears proper well-maintained footwear. Assure floor is free of glare, liquids, foreign objects, encourage R2 to assume a standing position slowly, encourage R2 to use environmental devices such as hand grips, handrails, keep call light in reach at all times, observe frequently and place in a high traffic area when out of bed, occupy R2 with meaningful distractions, provide R2 with an environment free of clutter, keep personal items and frequently used items within reach. Facility Fall Prevention and Management policy with revised date on 3/2022, denotes in part the purpose of this policy is to support the prevention of falls by implementation of preventive program that promotes the safety of resident based on care process that represents the best ways we currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualize, person centered care. The falls prevention and management program provide a framework and tools to identify and communicate about a resident risk of falls. Additionally, the program addresses a safe process to follow for supporting a resident who has experienced a fall event. Fall prevention and management practices includes separate activities. Universal fall precautions, standardized assessment of fall risk factors, care planning and interventions to address risk factors, post fall response including analysis of procedures and outcomes. Universal fall precautions are safety measures that are taken to reduce the chance of falls for all residents, regardless, of individual fall risk. The fall risk assessment is used to identify fall risk factors. Developing of fall risk care plan is based on results of the fall assessment as well as investigation of all circumstances and related resident outcomes. The care plan addresses universal fall precautions and individualize fall risk factors as applies to the resident. A fall care plan will be implemented as part of the baseline care plan to address universal fall precautions and as part of the comprehensive care plan utilizing information from the fall risk assessment. The care plan will be reviewed and revised at least quarterly and with any fall event the resident might experience. Alarms may be useful method of altering staff of a resident's movement which may pose a risk to their safety. Staff shall maintain communication with appropriate personnel when situations or resident behaviors suggest that the current interventions are not effective. The facility shall re-evaluate as needed to promote safety. Past history of a fall is the single best predictor of future falls. In fact, 30-40% of those residents who fall will do so again. This, it is critical for staff to respond quickly and effectively after a fall. A post fall response includes immediate actions to assure the safety of the resident, assessment/ clinical review, investigation and observation of the fall circumstance, implementation of immediate actions to prevent further falls, notification of appropriate parties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a resident who is fully dependent on staff for care from developing facility acquired pressure ulcers. This failure applied to one (R111) of six residents reviewed for pressure ulcers and resulted in R111 developing three facility acquired pressure ulcers; an unstageable wound to the left buttock, a stage IV wound on the left hip, and a stage IV to the sacrum. Findings include: R111 is a [AGE] year old female who was originally admitted to the facility on [DATE] with multiple diagnoses including: type II diabetes mellitus, dementia, depression, psychosis, hyperlipidemia, hypertension, hemiplegia, urinary incontinence, stage IV pressure ulcer of left hip, unstageable pressure ulcer of right ankle, stage IV pressure ulcer of sacral region, cerebral infarction, contracture of muscle, weakness, anemia, acute kidney failure, need for assistance with personal care, and dysphagia. MDS (Minimum Data Set) Annual assessment dated [DATE] notes that R111 has one facility acquired stage IV pressure ulcer and is totally dependent on staff for care, requiring 2+ staff assist for transfers and bed mobility. Per facility wound assessment since 10/11/22, resident has multiple facility acquired pressure ulcers including an unstageable to left buttock (2.0 cm x 1.5 cm) originally identified 10/11/22, stage IV to left hip (4.7 cm x 2.0 cm) originally identified 10/3/22, and a stage IV to sacrum (4.8 cm x 3.6 cm) originally identified 08/08/22. On 10/11/22 at 1:00 PM, V20 (Wound Care Registered Nurse) was observed performing wound care. V20 said R111's left hip and sacrum pressure ulcer are both facility acquired. She was also notified today of a new skin alteration. During treatment, V20 said the new skin alteration is a new facility acquired unstageable pressure ulcer (2.0 cm x 1.5 cm). Says the wound doctor does come once a week, typically on Mondays, to provide treatment. Per Wound Management Detail Report dated 09/22/22 and created by V15 (RN/ADON) states in part but not limited to the following: Left hip skin tear (4.0 cm x 4.0 cm) was originally identified on 09/22/22: Skin Tear Type: Total flap loss: entire wound bed exposed; Comments: Resident noted with new skin alteration to left hip. Per medical record documentation, wound care doctor did not see and assess this skin alteration until 10/3/22 (11 days later). Documentation from wound doctor on 10/03/2022 classified skin alteration as a stage IV pressure ulcer. There was no modification to the resident's plan of care to address this change in skin alteration. Last noted care plan interventions related to skin alteration were documented on 8/8/2022. Per Wound Management Detail Report dated 10/03/2022, created by V20 (RN) states (in part): Stage IV left hip pressure ulcer (5.0 cm x 2.0 cm) originally identified on 10/03/2022: Tissue Type: Necrotic Tissue, Wound edges/margins: well defined wound edges, Wound healing status: Declining, Comments: Seen by wound MD, wound reclassified. Wound bed 80% necrotic tissue, 20% skin. Wound noted declining, resident has poor appetite, and resident is bedbound. Review of medical record does not indicate that any additional assessment or care plan interventions were put in place to specifically address declining wound, resident's nutritional status, and lack of mobility. R111's current care plan with problem start date of 08/11/2016 includes: Problem: R111 is at risk to develop further pressure ulcers and/or skin breakdown due to diabetes mellitus, sepsis, dysphagia, hypertension, muscle weakness, difficulty walking, repeated falls, syncope and collapse, anxiety, incontinence, decreased mobility, and decreased body activity. Also requires total assistance to do activities of daily living. Goal: R111's wound sites will show signs of improvement through the next review date. Interventions include: Approach: Daily Skin Checks During the course of this survey, no documentation provided to show that resident was getting daily skin checks as ordered. On 10/12/22 at 2:00 PM, V15 (RN/ADON) was interviewed in regard to resident's active pressure ulcers. V15 said, the sacrum, left hip, and left buttock pressure ulcers are all facility acquired .originally identified the left hip wound as a skin tear due to it being superficial. R111 did have an order for weekly skin checks. It is noted that from 09/26/22 to 10/03/22 the wound deteriorated from a skin tear to a stage IV pressure ulcer. Asked V15, if in her experience, she has seen a wound deteriorate from a skin tear to a stage IV pressure ulcer in less than a week and she did not provide an answer. V15 said, it was noted that (R111) started declining in May of 2021. During the course of this survey, no documentation of modification to resident's plan of care to show that resident was declining or that interventions were put in place to address R111's decline. Facility policy titled 'Pressure Ulcer Prevention Protocol' dated 05/18 states in part but not limited to the following: Objective: Residents will be assessed to determine the risk factors for pressure ulcer development. Procedure: 4. Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks. Facility policy titled 'Pressure Ulcer Treatment and Management' dated 05/17 states in part but not limited to the following: Objective: Residents who receive treatment for pressure ulcers. Guidelines: 8. Residents with pressure ulcers will be determined to be at high risk for pressure ulcer prevention and all components of the At Risk protocol will include: pressure relieving devices, nutritional support, and assistance with mobility including repositioning and ROM as outlined in the At Risk Protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform an initial pain screening and comprehensive pain assessment upon readmission for a resident (R57) who is at risk for pain; failed to ensure an ongoing pain management program was implemented for a resident (R57) who required treatment and care that was not reflected in resident's individualized comprehensive care plan; failed to follow their facility policy and procedure for pain management. This failure has caused R57's pain level to remain consistently high without successful interventions by the facility. Findings include: On 10/09/2022 at 10:53 AM, surveyor heard yelling out while making observations on the third floor. At 10:55 AM, entered R57's room and observed resident lying in bed, sling loosely in place to left upper arm, and visibly experiencing pain. While weeping and holding her left upper arm, R57 said that she broke her arm and it hurts so much. R57 said, taking pain medicine but it is not enough. R57 said she last had pain medicine this morning and has asked for more, then said, the nurse, he knows. R57 then informed surveyor that she wants an increase in her pain medicine. When asked to rate her current pain level on a numerical scale of 0-10, R57 rated her current pain level at 20 then said it makes her feel bad and wants to die when having so much pain. On 10/09/2022 at 12:25 PM, reviewed R57's electronic medical record with the following noted: Past medical history not limited to Nondisplaced Fracture of Upper End of Left Humerus, Hypertensive Heart and Kidney Disease with Heart Failure and Stage 1-4 Chronic Kidney Disease, Unspecified Abnormalities of Gait and Mobility, and Pain in Left Shoulder. Active physician orders showed physical and occupational therapy ordered 5 times a week for 8 weeks, left arm sling related to nondisplaced fracture of upper end of left humerus daily, pain assessment every shift, lidocaine 4% apply 1 patch transdermal to left shoulder daily, zanaflex (tizanidine) 2 mg take 1 capsule at bedtime as needed for muscle spasm or muscle pain; acetaminophen 325mg 2 tablets as needed every 6 hours for mild (1-3) to moderate (3-6) pain, and hydrocodone-acetaminophen 5-325mg 1 tablet as needed every 6 hours for severe pain (7-10). readmission pain screening and comprehensive pain assessment dated [DATE] documents that R57 is unable to move 1 or more extremities, pain screening section 1 documents that in the last 5 days, R57 had vocal complaints of pain, had received scheduled and as needed pain medication. Pain assessment section indicates to complete for residents identified as experiencing pain in section 1. Section 2 and remainder of pain assessment which included diagnosis, frequency of pain, effect on sleep and activities, pain site, verbal descriptor pain scale, accompanying symptoms, character/duration/onset of pain, interventions and outcome was not completed for R57. On 10/10/2022, reviewed R57's electronic medical record with the following noted: Nurse Practitioner note dated 10/09/2022 12:48PM showed, Patient seen and examined at bedside. Care discussed with staff RN. Reason for the visit: LT shoulder/arm pain. HPI: Patient is a [AGE] year-old female seen today for complaints of LT shoulder/arm. c/o pain in LT shoulder/arm. resting in bed, appears agitated. on Norco 5/325 for pain control. Patient c/o severe pain despite Norco therapy. give one-time Norco 5/325 for breakthrough pain. increase Norco to 10/325 Q6hPRN. Nurse's note dated 10/09/2022 12:51 PM showed, late entry: resident continuous screamed for her PRN Norco 5-325 mg to be increased after ad med, stating it has not been strong enough to subside her pain. NP made aware and gave N.O to give resident another 1 tab of the Norco 5-325 mg and increased the strength of the Norco from 5-325 mg to 10-325 mg. Nurse's note dated 10/10/2022 07:23 AM reads, Patient was awake on and off, Received Norco from pharmacy at 0300 and a dose was given immediately. Nurse's note dated 10/10/2022 12:36 PM reads, Norco given for pain PRN as requested. R57's active physician's orders include order for hydrocodone-acetaminophen 10-325 mg 1 tablet Every 6 Hours PRN as needed for severe pain (7-10) with start date of 10/09/2022. R57's Care plan includes, (last reviewed 09/12/2022) at risk for alteration in psychosocial wellbeing; problem start date of 06/11/2021. Care plan also showed, R57 has alteration in Rest and Comfort r/t pain secondary to Polyneuropathy, Cellulitis of unspecified finger and diabetic amyotrophy, left humerus fracture. Edited: 10/10/2022. On 10/11/2022 at 1:26 PM, surveyor observed R57 lying in bed resting. She rated her current pain level on numerical scale of 0-10 at 3 then added when I move the pain is 10. On 10/12/2022, reviewed R57's electronic medical record with the following noted: Medication Administration History from 10/01/2022-10/11/2022 showed R57 received acetaminophen 650mg on 10/8 at 10:17am for pain to left shoulder rated at 6 and at 4:48pm for pain rated at 8. On 10/10/22, R57 received acetaminophen 650mg at 12:09am for pain rated 6. On 10/10/22, R57 received hydrocodone-acetaminophen 10-325mg at 3:27am for pain rated at 8 and at 12:22pm for pain rated at 5. On 10/11/22, R57 received hydrocodone-acetaminophen 10-325mg at 1:52am for pain rated at 7 and at 8:27am for pain rated at 7. It was noted that R57 did not receive her lidocaine pain patch to her left shoulder on 10/5, 10/7, 10/10, and 10/11 because patch was unavailable. Medication Administration History from 10/04/2022-10/09/2022 showed the following: 10/7/22 at 5:52AM, R57 received hydrocodone-acetaminophen 5-325mg for pain to left shoulder rated at 9. 10/07/22, R57 received hydrocodone-acetaminophen 5-325mg for pain rated at 7 at 12:00pm and again at 8:05pm for pain rated an 8. 10/08/22 at 5:58AM, R57 received hydrocodone-acetaminophen 5-325mg for pain rated at 7 - at 12:17pm for pain rated at 6 - and again at 10:50pm for pain rated at 8. R57's pain assessment on 10/4/22 documents that R57 rated her pain level at 8 on 2 of 3 shifts. 10/6 she rated her pain level at 7 during PM shift. On 10/7 she rated her pain level at 6 during PM shift. On 10/8, R57 rated her pain level at 6 on day shift and 8 on PM shift. On 10/10, she rated her pain level at 5 on day shift and 8 on PM shift. On 10/11, R57 rated her pain level at 7 on day shift. Nurse's note dated 10/11/2022 06:17 AM showed pain med @ 0153 given slightly relieved. On 10/12/2022 at 1:15pm, interviewed V3 (Director of Nursing) who said residents are assessed for pain upon admission then quarterly if identified. She then said when admitted with a diagnosis of a fracture and/or pain, the resident should have an initial pain screening and comprehensive pain assessment completed and a pain management care plan in place upon admission. V3 added that the nurse who completed R57's readmission assessment had missed multiple sections within the pain screening and assessment portion. Reviewed facility's Pain Management policy last reviewed/revised 05/17 that showed the following: Objective: It is the policy of this facility to screen all residents for pain; identify those who are experiencing pain; and assess and develop an effective individualized pain management care plan. Procedure: 1. All residents will be screened for the presence of pain symptoms. The facility nursing staff will complete the pain screening form upon admission, with quarterly assessments, readmission from hospital stay. 3. The resident without cognitive impairment will be assessed utilizing the numeric rating scale and verbal descriptor scale. 4. The physician will be informed of resident's initial complaint of pain and review the resident's pain management plan during routine visits. 5. An individualized pain management care plan will be developed for each resident who experiences pain.