Based on interview and record review, the facility failed to provide adequate supervision and implement effective care plan interventions for one resident (R2) who was reviewed for falls. This failure resulted in R2 experiencing a right hip fracture as a result of a fall.Findings include:R2 has multiple diagnoses including but not limited to the following: delirium, altered mental status, acute kidney failure, metabolic encephalopathy, dementia, insomnia, psychosis, cognitive communication deficit, difficulty walking, and lack of coordination.Fall Risk Evaluation dated 7/13/2025 shows R2 has a fall risk score of 22.0 indicating resident is at high risk for falls.It is to be noted that R2 was sent to the emergency room following a fall on 7/16/2025 and has not returned to the facility.Facility Reported Incident states in part but not limited to the following: On 7/16/2025 at approximately 6:28AM, V5 (Licensed Practical Nurse) was monitoring R2 in the dining area. R2 stood and attempted to walk, despite V5's attempt to redirect. R2 stumbled and fell to the floor, landing on her right hip. X-ray completed in-house revealed an impacted intertrochanteric fracture of the right femur.Progress note dated 7/16/2025 states in part but not limited to the following: While sitting at the nurses station charting, V5 looked up and noticed R2 standing up from her chair while in common area and attempting to walk. V5 jumped up and was instructing R2 to have a seat. V5 could not reach R2 in time and R2 landed on her right hip on the floor.Radiology Results Report dated 7/16/2025 shows an impacted intertrochanteric fracture of the proximal right femur with varus deformity.On 9/2/2025 at 12:50PM, V4 (Restorative Nurse) said R2 was high risk for falls. R2 was very impulsive and lacked safety awareness. R2 had a fall on 7/11/2025 where we put an intervention in place to ensure R2 was in the common area and receiving close monitoring. These residents in the common area should be closely monitored. I would expect the staff that is monitoring these residents to be within close proximity.At 1:53PM, V3 (Assistant Director of Nursing) said R2 was very impulsive and hard to redirect. She would try and get up and walk but was not safely able to.V3 said we place residents who are higher fall risk and need close monitoring in the common areas. The staff are expected to sit in the common area with them. It is not adequate supervision if a staff member is sitting at the nursing station while monitoring these residents. The staff would not have ample time to respond to a resident if they were to get up and attempt to walk.At 2:18PM, V6 (Certified Nursing Assistant) said R2 was very impulsive and needed constant redirection. R2 resided on the 2-North unit where a lot of residents with dementia reside. R2 and other high fall risk residents sit in the common area so that the staff can monitor them closely.V6 said we have a monitoring system in place where the staff is expected to rotate every 30 minutes in the common area to monitor these residents. They are expected to sit in the common area with these residents and be in close proximity. Monitoring the resident from the nurse's station would not be adequate supervision and the staff may not have enough time to respond if a resident were to get up.At 3:20PM, V5 said R2 had a lot of behaviors and would constantly try to stand up without asking for assistance. R2 was a resident that we constantly did rounds on because we knew she had these behaviors.On 7/16/2025, I witnessed R2 fall in the common area. R2 was consistently trying to stand up since had gotten up that morning. I was charting at the nurse's station and continuing to walk back and forth to redirect her and have her sit down. I had my back turned and was walking back to the nurses' station when I heard something move. As I turned around, I saw R2 attempt to walk and fall on her right hip.There were two CNA's on duty that early morning, but they were both assisting a resident out of bed that required two-person assistance. We have many residents that require two-person assistance on this unit. This unit typically has a census of 43-50 residents and most of them have dementia and behaviors. I was the one responsible to monitor the residents in the common area at the time since the two CNA's were occupied providing care. However, I do not feel as if this is adequate staffing to properly care for all these residents.R2's Fall Care Plan intervention added on 7/11/2025 shows R2 should be placed in common area while awake for close monitoring.Facility Fall Prevention and Management Policy with last review date of 2/2025 states in part but not limited to the following: The facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their hospice policy and care plan for one (R2) out of three residents reviewed for mechanical lift for transfer from chair to bed. This failure resulted in R2 sustaining a laceration on her left leg that required R2 to be sent to the emergency room for suturing. The after-emergency room summary indicates that R2 was treated for laceration repair. The facility's final summary investigation indicates that R2 returned to the facility with 17 sutures. Findings include:On 8/19/2025 at 11:37 AM, V4(Hospice CNA) said that V4 was transferring R2 to the bed, and V4 bumped R2's leg on the bed. V4 said that was when V4 saw the blood and V4 ran to get the nurse. V4 said that V4 transferred the resident from the wheelchair to the bed by herself. V4 said that R1 is a mechanical lift transfer resident. V4 said that V4 just did not use the mechanical lift and that was a mistake on V4's part. On 8/20/2025 at 1:50 PM, V4 said that V4 has been working with R2 for about 2 months. V4 said that V4 has been working as a CNA for about 17 years. V4 said that V4 received training on how to use mechanical lift from the hospice agency V4 works for. V4 said that V4 was not oriented on the facility mechanical lift. V4 said that although V4 was aware that R2 needs mechanical lift with 2 persons assist transfer, V4 said that V4 never uses the mechanical lift when transferring R2 from the chair to the bed since V4 has been caring for R2. V4 said that when V4 starts her shift, R2 has already been transferred from bed to her chair. V4's response to why V4 did not ask for assistance for transferring R2 was that everyone is busy doing their own thing, and as long as you do your job, you have no problem. V4 said they never had a situation like this since V4 has been working as a CNA, and V4 said that V4 felt bad for what happened.On 8/19/2025 at 2:01PM, V5 (LPN) said that the incident happened at the end of shift and V5 was the oncoming nurse. V5 said that V6 was the day nurse who V4 notified of the incident. V5 said that the wound care was notified of the injury and was already assessing the resident's injury when V5 went to see R2. V5 said that wound care nurse did her assessment and V5 notified the doctor and obtained an order for R2 to be sent out to the emergency room.On 8/19/2025 at 2:11 PM, V6 (LPN) said that V6 was R2 daytime nurse, and the incident happened around change of shift. V6 said that V6 was called into R2's room by V4. V6 said that V4 informed V6 that there is a cut on R2's leg. V6 said that V6 cleansed the area and applied a temporary bandage until the wound care nurse came down. V6 said that V6 notified the hospice nurse, wound care nurse, and then endorsed to V5. V6 said that no signs of pain or distress was notified. V6 said that to the best of her knowledge, it was the first time that V4 transferred R2 without the mechanical lift.On 8/19/2025 at 2:37 PM, V7 (CNA) said that R2 was assigned to her for the PM shift and V7 took care of R2 when she returned from the hospital 8/5/2025. V7 said that V7 was in room [ROOM NUMBER] performing patient care for the 2 residents in room [ROOM NUMBER]. V7 said that V7 was rounding on other residents. V7 said that she did not witness what happened. V7 said that R2 is 2 persons assist for transfer with Mechanical lift. V7 said that every time V7 takes care of R2, she always uses the mechanical lift when transferring R2.On 8/20/2025 at 12:29 PM, said V2 (ADON) said that V2 has been the facility ADON since 4/2025. V2 said that is little bit familiar with what is in the facility hospice policy but not word to word. The surveyor read out #7. protocol on the hospice policy which states, that the written contract between the facility and the hospice company must include, an agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's care and nursing needs in coordination with the hospice representative, and ensure that level of care provided is appropriate based on the individual resident's needs. V2 said that V4 should have used the mechanical lift during R2's transfer. V2 said that V2 is not aware of V4 being the CNA that cares for R2. V2 said that normally, hospice aide request assistance from the facility aide. V2 said that V4 should have requested for assistance and used the mechanical lift to transfer R2.On 8/20/2025 at 12:48 PM, V8 (Hospice Nurse) said that V8 said that V8 has been the nurse for R2 since 4/2022. V8 said that V8 received a phone call from V4 (Hospice CNA). V8 said that V4 told V8 that V4 was transferring R2 from the chair to the bed using 1 person transfer. V8 said that V4 said that when V4 laid R2 in bed, V4 noticed blood on R2's leg. V8 said that V4 said that V4 does not know how it happened. V8 said V8 used company issued Microsoft team to video chat with V4 to see R2's wound. V8 said that the wound looks to V8 as a deep skin tear. V8 said that V4 informed V8 that V6 (R2's facility RN) and wound care nurse were notified already. V8 said that V8 spoke to V6 and instructed V6 to send R2 to the ER for sutures. V8 said that V8 notified V3 (R2's son) about R2's injury and V8 recommendation for R2 to be sent out to ER for sutures. V8 said that V3 told V8 to have the facility call V3 when R2 is sent to the ER. V8 said that V8 called the facility and spoke to V5 (R2's PM shift RN) to call V3 when R2 is sent to the ER. V8 said that R2 is a mechanical lift with 2 persons assist transfer. V8 said that V4 has been working with R2 for about two months. V8 said that V4 should have used the mechanical lift when transferring R2. On 8/20/2025 at 1:59 PM, V1 (Administrator) said that V1 was on vacation when the incident happened. V1 said that what V1 knows, is what was reported. V1 said that R2 is a mechanical lift with 2 persons assist for transfer. V1 said that the floor nurse is V4's direct supervisor. V1 said that but the floor nurse is not expected to be directly overseeing R4's work. V1 said that the facility expectation is for the hospice company to send an aide with competent skills. V1 said that V4 (Hospice Aide) should have used the mechanical lift when transferring R2.Physician progress note dated 8/6/2025 at 12:36 PM stated, patient was being transferred without the use of a Hoyer lift and in the process of the transfer she sustained a laceration to her left calf. A photo of this wound was sent to me which appeared to be quite deep and long and therefore I advised staff to send her to emergency room for suturing.R2 is a [AGE] year-old lady admitted into the facility on 6/30/2017 with a brief interview of mental status of 00/15. Review of R2's physician order summary indicates that R2 was admitted to [NAME] Hospice on 4/21/2022. Review of facility report to IDPH of patient incident that occurred in the facility on 8/5/2025 indicates that R2 sustained an injury to her left calf during a transfer which led R2 to be sent to ER for placement of sutures. The report also indicated that R2 returned to the facility with 17 sutures. Review of the ER after visit summary indicated that R2 was treated for laceration closures. Review of the hospice nurse aide care plan and facility care plan for R2 indicate that R2's transfer from bed/chair and chair/bed should be done with a mechanical lift with 2 persons assist. [NAME] HEALTH CARE GUDELINE - HOSPICEMANUAL - NURSINGREVIEW DATE - 1/2025 GENERAL: To provide guidance on how hospice services will be administered within the facility. A written agreement with the hospice that is signed by an authorized representative of the hospice provider and an authorized representative of the LTC facility before hospice care is furnished to a resident.PURPOSE: Ensure that the hospice services meet the professional standards and principles that apply to individuals providing services in the facility, and to the timelines of the services.RESPONSIBLE PARTY: IDTThe written contract must include the following:PROTOCOL:#7. An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice environment, and ensure that the level of care provided is appropriate based on the individual resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to conduct comprehensive assessment and implement wound care management for one (R1) of three residents reviewed for skin alteration. This deficiency resulted in R1's abrasion on the left great toe deteriorated to necrosis, gangrene, infection of left foot, and needs amputation. Findings include:R1 is an [AGE] year-old, male, admitted in the facility on 07/03/25 with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Type 2 Diabetes Mellitus without Complications; Pain in Right Foot; Pain in Left Foot; and Multiple Subsegmental Thrombotic Pulmonary Emboli without Acute Cor Pulmonale. MDS (Minimum Data Set) dated 07/10/25 recorded R1's BIMS (Brief Interview for Mental Status) score is 0, which means severe cognitive impairment.R1's progress notes documented:07/03/25: received R1 in stable condition. The left great toe had a D/I (debridement and irrigation) done, has order for Silvadene 1% topical cream with dressing daily, and to follow up with Podiatry.07/04/25 - Skin/Wound note: abrasion noted to the left great toe with some discoloration. R1's POS (Physician Order Sheet) dated 07/03/25 recorded: Silver Sulfadiazine external cream 1% (Silver Sulfadiazine) apply to left great toe, nail area topically one time a day for dermatology.Wound assessment detail report dated 07/04/25 documented R1's Left toe as abrasion present upon admission, measuring 4 cm (centimeters) x 2 cm x 0.10 cm with light amount of blood exudate.On 07/28/25 at 11:28AM, V5 (Wound Care Coordinator) was asked regarding R1's abrasion on the left great toe. V5 stated, When he (R1) was admitted , he was assessed to have abrasion on the left great toe. Initially he came from the hospital with orders of Silvadene cream and we were applying it. Then the podiatrist (V10) saw him two to three days prior to discharge and changed the order to betadine and dry dressing. R1's POS documented the following:07/09/25: Cleanse left great toe with normal saline, apply betadine-soaked gauze and a dry dressing, every 8 hours as needed for if soiled or dislodged.07/09/25: Cleanse left great toe with normal saline, apply betadine-soaked gauze and a dry dressing, every day shift every Tue, Thu, Sat to promote skin healing. Medical Practitioner note dated 07/12/25, authored by V10 (Podiatrist) recorded the following:Date of service 07/09/25Physical Exam: Integument - necrosis of left hallux noted. R1 was seen by V10 on 07/09/25, noted necrosis of the left hallux. However, wound assessment details reports dated 07/11/25 still documented his (R1) left toe as abrasion, measuring 4 cm x 2 cm x 0.10 cm, with light amount of bloody exudate.On 07/28/25 at 12:05PM, V6 (Licensed Practical Nurse/Treatment Nurse) was asked regarding R1's wound on the left great toe. V6 verbalized, Upon admission, he had an abrasion to his left great toe with some discoloration. He had admitting orders from hospital for Silvadene. When I did the assessment, he had the abrasion to his left toe with discoloration. The wound was bluish dark in color, had some discharges under nail, the nail was still there, there was pain but no swelling. R1's medical practitioner progress note dated 07/10/25 recorded:Plan: Cellulitis and necrosis of left great toe; wound care on consult with wound care orders, in ongoing antibiotics. On 07/29/25 at 11:56AM, V10 was interviewed regarding R1. V10 replied I've seen him last 07/09/25 because of wound care toenail debridement. There was gangrene, necrosis on his left hallux (great toe). Gangrene could be dry or wet. He has dry gangrene, with dead tissues, necrotic. It was treated with betadine and dry dressing. When I talked to V5, she said she is already taking care of it and wound care is seeing the resident (R1). But I still made a note, I wrote it in a prescription pad regarding referral to wound care. I wrote there to please evaluate and treat wound care consult. I want to make sure wound care team is following the resident (R1). Gangrene can get worse in a few days. Gangrene is from poor blood supply. If there is no blood supply, the wound cannot heal.On 07/29/25 at 10:40 AM, a follow - up interview with V5 was conducted regarding R1's wound care consult. V5 mentioned, R1 was not referred to wound care because it was only an abrasion. Wound Doctor does not see skin tear or abrasions.R1's POS dated 07/04/25 documented: May be seen by Wound Care Specialist.Progress notes dated 07/13/25 indicated that R1 was sent to the hospital due to wound on left toe, per family's request.Progress notes dated 07/14/25 documented R1 was admitted in the hospital with diagnosis of cellulitis of great left toe.Hospital records dated 07/13/25 documented the following:1. Infectious Disease Consultation 07/14/25Impression: Left hallux gangrene, diabetic infection of left foot.Active problems: Paronychia of great toe; necrotic toes; sepsisSuspect (R1) will need amputation. Wet gangrene without surrounding cellulitis.2. Xray (XR) of toe, 1st great left, 07/13/25: Narrative: XR toe 1st great left indication: Left toe infection3. History and Physical 07/14/25Date patient seen: 07/14/25Assessment and plan: Left great 1st toe necrosis; diabetic infection of left footPresented for left great toe evaluation, found to have black necrotic toe suspicious for diabetic foot wound infection with superimposed element of ischemia due to PAD (Peripheral Artery Disease). It is unclear when left great toe changes started, rest of HPI (history of present illness) limited due to patient dementia.Physical examination:Skin - necrotic and black left great toe. R1's care plan documented:1. Potential and is at risk for alteration in skin integrity: Abrasion to the left toe.Interventions:Monitor for signs and symptoms of infectionTreatment orders in place.Notify MD (Medical Doctor) and responsible party of any significant changes.2. admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation and assessment of the patient's condition.Interventions:Provide skin treatments per MD order. Follow plan of care for skin management. On 07/30/25 at 11:59AM, V3 (Assistant Director of Nursing) was also interviewed regarding R1. V3 verbalized, He has wound to his left toe. The left toe is dark in color. Wound care nurse does the treatment, Silvadene cream. When wound is necrotic, wound care MD has to see it. Facility's policy titled Skin Care Prevention dated 1/2025 stated in part but not limited to the following:General: All residents will receive appropriate care to decrease the risk of skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat elevated blood sugars that were above the resident's baseline before it got to a critical level and the facility failed to put in any interventions for a resident experiencing vomiting and diarrhea to prevent dehydration. This affected two of three (R81, R84) reviewed for nursing quality of care. This failure resulted in R84 being sent to the hospital with a blood sugar level of 521 mg/dL and was diagnosed with uncontrolled diabetes and R81 being sent to the hospital to be treated for severe dehydration after being diagnosed with norovirus. Findings Include: R81 is an [AGE] year old with the following diagnosis: chronic obstructive pulmonary disease, nontraumatic intracerebral hemorrhage, chronic kidney disease, congestive heart failure, and peripheral vascular disease. R81 was at the hospital from [DATE] through the evening of 4/23/25. A Nursing note dated 4/18/25 at 2PM documents the nurse was notified by staff that R81 appeared to be choking. Upon entering the room, the nurse observed emesis and mucous on R81's shirt. The nurse assisted R81 with cleaning up and clearing throat of sputum. The oncoming nurse was made aware in report. A Nursing note dated 4/18/25 at 5:35PM documents the nurse was made aware by the coming nurse that R81 had sputum in the mouth. The nurse still observed sputum coming from R81's mouth. An allergy spray was ordered for R81's nose for seasonal allergies. An order for an antidiarrheal medication was also placed. A Nursing note dated 4/18/25 at 8:57PM documents V37 (Family member) called the nurse to the room because R81 had a very large watery stool. Staff cleaned R81 and administered the antidiarrheal medication. Vital signs show s blood pressure of 107/51. V37 was adamant on sending R81 to the hospital after the staff explained interventions could be put in place at the facility. V37 still insisted on sending R81 to the hospital stating something is wrong. A Nursing note dated 4/19/25 documents R81 was admitted to the hospital with a diagnosis of colitis. The Hospital Records dated 4/18/25 document R81 arrived to the emergency department with a chief complaint of low blood pressure. The admitting diagnosis was colitis and altered mental status. R81 presented from the nursing home back from hospice with nausea, vomiting, and diarrhea. Blood pressure is in the high 90s to low 100s. R81 was somnolent and wakes to loud voice and shoulder taps. Per family, R81 has been complaining of abdominal pain and having diarrhea for the last four days. Stool studies are pending, but R81 was put on two oral antibiotics at this time. V37 reported the facility gave R81 an anti-diarrheal medication, but R81 started having profuse and voluminous amounts of diarrhea. Family also reports R81 having violent vomiting as well. R81 is ill appearing. Mucous membranes are dry. Lab levels revealed a BUN level of 37 in creatinine of 1.66. Both of these levels are high, indicating dehydration. Stool studies eventually came back positive for norovirus. R81 received supportive treatment with IV fluids and retuned back to the facility. On 4/22/25 at 11:15AM, V37 (Family member) stated the staff do not respond to any changes in condition of residents. V37 stated R81 has had to be sent out to the hospital twice within the last two months where V37 had to ask staff to send R81 out of the hospital because there were changes V37 was concerned about that staff didn't think were serious. On 4/24/25 at 2:31PM, V28 (Nurse) stated V37 was at R81's bedside reporting to staff that R81 was having loose stools. V28 did not know the exact amount of times R81 had an episode of diarrhea but stated V28 was present in the room when R81 had two loose bowel movements. V28 described the bowel movement as liquid diarrhea. V28 reported telling V37 that interventions could be done in the hospital but V37 wanted R81 sent to the hospital because the blood pressure was low. V28 reported the blood pressure was 100s over 50s and confirmed this was a lower blood pressure for R81. V28 stated R81 was on hospice and only to receive comfort care. V28 reported the diarrhea was a new symptoms since starting hospice. V28 stated V28 called and got an order for an anti-diarrhea medication and administered it to R81 but did not do any further testing due to R81 being on hospice. V28 was not aware about any vomiting R81 was having. V28 reported when a resident has a change in condition and assessment needs to be done and vital signs need to be taken. V28 reported if anything is abnormal than the physician must be made aware. V28 stated signs of dehydration would be sunken eyes, dry mouth, low blood pressure, and increase heart rate. V28 defined a change in condition as anything observed that is out of the regular for a resident. V28 reported based on what V37 said R81 had a change in condition, but no aggressive interventions were pursued due to being on hospice. V37 denied R81 showing any signs of dehydration before being sent to the hospital. On 4/24/25 at 2:55PM, V29 (CNA) stated throughout the shift, R81 threw up multiple times and had multiple episodes of diarrhea. V29 reported working with R81 on the 2 PM to 10 PM shift. V29 stated R81 had 2 to 3 episodes of diarrhea before dinner and two more episodes of diarrhea after dinner. V29 reported the quantity of diarrhea was large amounts that caused R81 to need an entire bed change because the diarrhea had leaked all over the bed. V29 was not able to state the amount of time R81 vomited. V29 reported the nurse was also in and out of the room and notified of every episode of diarrhea or vomiting. V29 stated R81 was sent out to the hospital per V37's request. V29 reported that R81 verbalized to V29 that R81 did not feel good and had been quieter. V29 stated R81 is normally very confused and will answer baseline questions, but was struggling to even do that before being sent out. V29 reported signs and symptoms of dehydration are dry mouth. V29 denied R81 having any intake from 2 PM until the time R81 went out around 8 PM. V29 denied being aware if R81 had any other intake earlier in the day. V29 reported R81 kept having spit up in R81's mouth so it was difficult to tell if R81's mouth was dry. On 4/25/25 at 9:36AM, V31 (Attending Physician) stated R81 has a poor baseline health. V31 reported all hospitalizations are driven by V37 even though R81 is on hospice. V31 reported R81 is to receive comfort measures only but V37 still wants R81 to be sent out. V31 defined a change of condition as any change from baseline with paying special attention in any changes to vital signs. V31 stated R81 is on a hospice for a general decline in health and poor quality of life. V31 denied the diarrhea having to do with why R81 was on hospice. V31 stated V31 would expect staff to evaluate a resident and take vital signs and then let the physician know so further testing could be ordered if needed. V31 stated with a diagnosis of norovirus there is no medication that can be given to treat the virus, but comfort measures would have been provided to treat the symptoms. V31 reported it is also not recommended to give any anti-diarrhea medication for this virus as it could make the diarrhea worse. V31 reported comfort measures include treating the nausea and vomiting with medication and hydrating the resident with IV fluids but if they can't stay hydrated with oral intake. V31 stated if comfort measure do not work to keep them stable then they need to be sent to the hospital. On 4/24/25 at 10:52AM, V2 stated anything opposite noted from the original admission assessment is considered a changing condition. V2 reported any change in assessment means a physician needs to be notified so they can be aware and provide additional orders to the nursing staff if needed. V2 stated V37 reported that R81 aspirated. V2 reported once V2 entered the room R81 was coughing and had sputum in the mouth. V2 stated R81 had loose but formed stool at first. V2 stated R81 had another episode of sputum in the mouth and V37 requested to send R81 to the hospital. V2 reported that V2 was only aware of the one episode of diarrhea and no staff notified V2 of any additional episodes of vomiting or diarrhea. V2 stated R81 eats by mouth. V2 reported hospice residents are usually not sent out to the hospital once they're on hospice but V37 has requested to send R81 out to the hospital for an evaluation. V2 stated signs of dehydration would be increase heart rate, low blood pressure, not urinating as much, and dry mouth. Vital signs for 04/2025 document an average blood pressure for R81 of 130-150s/60-70s from 4/12/25-4/17/25. The blood pressure documented on 4/18/25 at 8:28AM was 102/60, at 1:31PM was 102/61, and at 8:11PM 107/51. Normal pressure is around 120/80. The blood pressures documented on 4/18/25 are low for R81. The SBAR Communication Form dated 4/18/25 documents R81 is having a change in condition of loose stools. No additional testing was completed. R81 was sent to the hospital per V37's request. The Transfer Form dated 4/18/25 documents the reason for transfer as diarrhea. R81 remains at baseline mental status of confused but able to follow simple directions. The Care Plan dated 9/4/23 documents R81 has renal insuffiency related to chronic kidney disease stage three. An intervention includes to monitor for sing or symptoms of hypovolemia and monitor vital signs. This care plan also documents R81 is at risk for dehydration or potential fluid deficit related to history of electrolyte correction and poor oral intake. An intervention includes to monitor for signs or dehydration. The policy titled, Change in Resident Condition, dated 01/2025 documents, General: It is policy of the facility, except in a medical emergency, to alert the resident, resident's physician, and resident's responsible party of a change in condition. Policy: Nursing will notify the resident's physician or nurse practitioner when: .b. There is significant change in the resident's physical, mental, or emotional status .e. It is deemed necessary or appropriate in the best interest of the resident. R84 is an [AGE] year old with the following diagnosis: Alzheimer's disease, type 2 diabetes, and acidosis. R84 is not able to communicate due to mental status so no questions were able to be asked by the surveyor about this incident. A Nursing note dated 12/16/24 documents R84 was transferred out to the hospital. A Nursing note dated 12/17/24 documents the nurse called the hospital to inquire on the status of R84. R84 was admitted with uncontrolled diabetes and altered mental status. The Blood Sugar Summary for 12/2024 documents R82 has a blood sugar range of 143-246 mg/dL from 12/1/24 through 12/13/24. A normal blood sugar is 60-100 mg/dL. On 12/14/24 at 8:47AM, the blood sugar was 399 mg/dL. On 12/15/24 at 9:00AM, the blood sugar was 304 mg/dL. On 12/16/24 at 11:39AM, the blood sugar was 178 mg/dL. On 12/16/24 at 5:30PM, the blood sugar was 521 mg/dL. The Transfer Form dated 12/16/24 documents R84 was sent to hospital for abnormal vital signs with the most recent blood glucose being 521 mg/dL. A Nurse Practitioner note dated 12/26/24 documents R84 readmitted to the facility on [DATE] after a hospitalization where R84 was diagnosed with lethargy and metabolic encephalopathy. Blood sugars are now controlled. On 4/24/25 at 3:30PM V30 (Nurse) stated V30 define a change in condition as anything that is out of the baseline for a resident's physical status or behaviors. V30 reported each resident has their own baseline and if anything is out of the ordinary, then an assessment must be completed to try to see what is going on. V30 reported there are parameters for certain laboratory levels, and vital signs so the physician can be made aware of what is going on with the resident. V30 reported even if the vital signs or laboratory levels are still within perimeter than the physician still needs to be notified if there is a change. V30 stated nurses need to use their judgment to decide when a resident is having a change of condition. V30 stated the physician needs to be made aware of a change in condition to see if any additional orders need to be put in place so whatever is going on can be managed in the facility. V30 reported that all changes in condition need to be documented and when the physician was notified. V30 stated if a change in condition is not addressed when it is first noted by the nurse, then a situation and the patient's health could decline. On 4/25/25 at 5:03PM, V38 (Former Nurse) stated V38 cared for R84 during the evening shift. V38 reported residents were receiving insulin need to have blood sugars checked before meals and bedtime. V38 could not remember the exact number of R84's blood sugar but knew it was over 500 and considered a critical level. V38 denied being aware that R84 was having a change in condition of elevated blood sugars in the 300s before the blood sugar hit 500. V38 stated once the blood sugars got to the level of 300 then a physician should have been notified because R84 normally did not have blood sugars in the 300s. V38 reported R84 was only ordered a long acting insulin at that time and not on a sliding scale insulin which could have provided additional insulin for R84. V38 reported R84 is not able to speak due to mental status so it was not possible to ask how R84 was feeling. V38 stated by notifying the physician when the blood sugars were in the 300s R84 could have possibly been treated at the facility and not had to go out to the hospital for uncontrolled diabetes. On 4/25/25 at 9:36AM, V31 (Attending Physician) stated a parameter on when to notify a physician should be put in place for a resident who is receiving blood sugar checks. V39 reported basic protocol usually does not have staff notify a physician of elevated blood sugar until the blood sugar is over 400. V31 stated if the blood sugar has become more elevated than usual than an order for extra insulin or labs could be put in place to assess any additional causes of why the blood sugar might be elevated. V31 reported a blood sugar of over 500 indicates a resident is in diabetic keto acidosis (DKA). V31 stated it is caused due to a lack of insulin in the blood and needs to be treated at a hospital once it gets to the level of DKA. On 4/25/25 at 10:52AM, V2 stated if a resident is having blood sugars that are elevated into the 300s that is not their normal then a physician should be notified to see if additional orders need to be put in place. V2 reported if the blood sugar is left untreated than the blood sugar will remain elevated or increase. V22 was unable to answer why a physician was not notified of our 84 elevated blood sugar in the 300s before it reached 500. The Physician Order Sheet documents an order for blood sugar checks before meals and at bedtime that was ordered on 10/25/24. There are no parameters for when staff should notify the physician or an elevated blood sugar. R84 was ordered the following medications for diabetes before going to the hospital: Gilmepiride oral tablet 2mg daily, Jardiance oral tablet 25mg daily, Metformin oral tablet 1000mg, and Lantus Subcutaneous 100 unit/mL for 8units once a day. After the hospitalization in 12/2024, an order was placed for Humalog insulin 100 unit/mL on a sliding scale based on blood sugar checks. The Medication Administration Record dated 12/2024 documents R84 received the medication as ordered for diabetes mellitus. The Care Plan dated 10/25/24 documents R84 is at risk for hypo/hyperglycemia related to diabetes mellitus. R84 receives routine insulin and PO medication for glycemic control. R84 was recently hospitalized with diabetic ketoacidosis. Interventions include: accuchecks as ordered and monitor/document/report to the physician as needed for signs and symptoms of hyperglycemia. The policy titled, Diabetes Management, dated 01/2025 documents, General: To provide guidelines for the management of diabetic residents. Guideline: .3. Diabetics who require blood glucose monitoring due to insulin use should have parameters for when the physician should be notified and how insulin should be adjusted. The policy titled, Blood Glucose Monitoring, dated 3/2025 documents, General: To provide guideline for managing blood glucose. Guideline: Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring.

Based on interview and record review the facility failed to implement effective fall intervention to prevent a resident from falling which resulted in resident walking by herself, falling, and sustaining a left hip fracture. This failure affected 1 resident (R2) of 3 residents reviewed for falls in a total sample of 15. Findings include: On 7-3-24 at 11:12 AM, V2 (Director of Nursing) said R2 is primarily Spanish speaking and R2 can make simple needs known. V2 said R2 has poor safety awareness due to dementia, impulsive behaviors, and gets up by herself without asking for assistance. V2 said R2 will become aggressive during redirection which could lead to falls. V2 said R2 has unsteady gait and requires 1-person assistance and assistive walking device. V2 said R2 is a fall risk. V2 said CNA cleaned, dressed, and brought R2 to common area. V2 said high fall risk residents were grouped in common area and supervised. V2 said CNA left the group to give ADL care. On 7-3-24 at 8:50 AM, V20 (Certified Nurse Aide) said R2 is alert and able to make her need known in simple terms since R2 is primarily Spanish speaking. V20 said R2 has periods of confusion, can be impulsive, and constantly tries to get up by herself. V20 said when staff redirect R2, R2 becomes combative. V20 said R2 tries to get up out of her bed and wheelchair. V20 said R2 attempts to walk to other rooms without her wheelchair and walker. R2 is a high fall risk due to unsteady gait, confusion, and impulsive behavior. V20 said all staff is aware of fall risk thus R2 is placed in common area for supervision and staff takes turn to supervise fall risk group. V20 said high risk for fall residents are kept in a group and supervised by 1 or 2 staff. V20 said she was giving R2 care when nurse discovered R2 on the floor. V20 said she cleaned and dressed R2 less than 30 minutes prior to the fall. V20 said she was supervising R2 in the common area during the night shift. V20 said she had to leave the group and give patient care for the next shift. V20 said she told the nurse she was going to do CNA rounds and nurse said OK. V20 said nurse was at nurses' station and went to pass medications. V20 said she heard R2 boom from a fall. V20 said she came out of the room and nurse was standing over R2. On 7-2-24 at 2:10 PM, V21 (Registered Nurse) said R2 is alert, oriented x 1-3, and with occasional confusion and stubbornness. V21 said R2 has no safety awareness due to confusion and impulsive behaviors. V21 said R2 is a high fall risk due to unsteadiness on her feet, confusion, and poor safety awareness. V21 said R2 requires 1 person assistance with transfers. V21 said she does hourly rounding when R2 is in her room. V21 said most of the high fall risk residents are kept in common area under staff supervision. V21 said R2 does not use the call light and R2 will get up by herself. On 7-3-24 at 10:32 AM, V19 (Licensed Practical Nurse) said R2 is alert, oriented x1-2, and able to make simple needs known. V19 said R2 has occasional confusion and R2 has no safety awareness. V19 said R2 is a fall risk and believes she can do things independently but can't. V19 said R2 will try to stand up and walk, take herself to the bathroom, and gets up without telling any staff. V19 said R2 requires assistance due to fall risk and history of falls. V19 said she was ambulating around the nurses' station, V19 redirected, and R2 became aggressive. V19 said she just finished passing medications and noted R2 ambulating by herself. V19 said CNA cleaned and dressed resident prior to incident. V19 said R2 was unattended at that time. V19 said R2 requires 1:1 because she tries to do things by herself. V19 said she was passing medications and CNA did not mention R2 was placed in common area or CNA was leaving R2 unattended. R2's admission Evaluation dated 5-23-24 documents: 1h. 19 (A score of 10 or higher indicates a High Fall Risk). Fall Risk Evaluation dated 5-24-24 documents: Score: 26 (Scoring a 10 or higher makes resident high risk for falls). State Reportable dated 5-24-24 documents: Incident Description: Resident was observed ambulating the hall, when nurse on duty attempted to redirect to seating area, she became resistant/ combative, NOD then allowed resident to ambulate and followed close behind as to not agitate resident further. While walking behind her, (R2) stumbled, falling to the floor and NOD was not able to break her fall. Upon assessment, (R2) left leg appeared to be shortened. Resident sent to ER for eval and was admitted with L hip fx. NOD made MD aware, received orders to send resident to ER for eval. EMS called; ETA of 30-60 minutes was given. Responsible party notified and agreeable with plan of care. NOD called ER and was made aware that resident was being admitted with dx of left hip fx. Investigation is ongoing. State Reportable (Final) documents: Summary of Investigation: (R2) had been awake and trying to ambulate since 1 am, when she was placed in common area for monitoring. At 0540, (R2) was observed ambulating and the nurse attempted to redirect her to the seating area, but (R2) became resistant and combative, so nurse allowed her to walk, but followed close behind her to not to agitate her to walk but followed close behind her not to agitate her further. As the resident continued to ambulate, she stumbled, falling to the floor, and the nurse was not able to break her fall. Hospital Record dated 5-24-24 documents: admission Diagnosis: (not limited to:) Closed left hip fracture, Displaced fracture of left femoral neck. Inpatient Problem List: Displaced fracture of left femoral neck, Closed left hip fracture. Principal Problem: Closed left hip fracture. Left hip fracture traumatic on pathological secondary to osteoporosis. Chief Complaint: witnessed fall. History of Present Illness: (R2) is an 81 y.o. female history of dementia, essential hypertension, generalized anxiety disorder, presented to hospital due to weakness falls at the nursing home resulted in left hip fracture she was admitted for surgical intervention per Ortho on consult. Progress note dated 5-24-24 documents: Resident was noted ambulating the unit. This writer came upon resident and was attempting to assist her to a chair. Resident became resistant/combative. This writer allowed resident to walk while walking behind her. Resident stumbled and fell to the floor; this writer was unable to break her fall. Resident landed into the CNA cart and ended up on her left side on the floor. Resident immediately grabbed her left leg and shouted in pain. Left leg appears shortened. This writer reached out to daughter and made her aware of situation. Orders received to send to Hospital for eval. All parties aware. Fall Prevention and Management Policy dated 1-23 documents: General: This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for fall, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise one resident while sitting in the dining room unattended who was identified as a high fall risk and has a diagnosis of Dementia, syncope, and a history of falls. This failure resulted in R401 having an unwitnessed fall from her wheelchair sustaining a left hip fracture. The facility also failed to utilize a leg rest during a transport for a wheelchair bound resident. This failure resulted in R61 having a fall from the wheelchair sustaining a right forehead hematoma. These failures affected two of three residents reviewed for falls in a total sample of 26. Findings Include: R401 was diagnosed with Dementia, Syncope and Collapse. Minimal data set Section GG (functional abilities and goals) dated 3/31/24 documents: R401 required partial/moderate assistance for sit to stand (the ability to come to a standing position from sitting in a chair. Helper lifts, holds or support trunk or limbs but provides less than half the effort). Comprehensive restorative assessment dated [DATE] documents: History of falls in the past 1-6 months, S/P Fall and/or Fracture in past 6 months. Fall Risk Scoring: Add up the numbers of the responses above twenty-two. Fall risk scoring: ten or above: high fall risk. On 5/14/24 at 1:01PM, V4 (restorative nurse) said R401 had an unwitnessed fall. V22 (CNA) saw R401 on the floor. No staff was in the dining room when R401 fell. Staff should have been in the dining room monitoring R401. On 5/15/ 24 at 12:51PM, V22 (cna) said she saw R401 on the floor after a resident mentioned R401 had fallen. V22 said R401 used a rollator walker to assist with ambulation. V22 said she saw R401's walker unlocked after the fall. V22 said at the time of R401's fall no staff was in the dining room. Staff was moving residents from the dining room to the television room. V22 said no staff was monitoring R401 when R401 fell. Nursing note dated 03/31/24 documents: V47 (nurse) was called to the dining room by a CNA at 1:15pm stating resident fell on the floor and was laying on her left side. Fall was unwitnessed. R401 observed laying on the floor on her left side. When asked what occurred R401 stated in broken English, stood up, lost balance. R401 complained and was rubbing area of left hip/leg stating it hurts. R401 was assisted onto her rollator walker with staff assist. POA was called to try to translate R401's pain and what occurred. R401 with Dementia diagnosis. M.D called and order was obtained to send to emergency room (ER) for evaluation. POA (power of attorney) requested call 911. 911 called, Paramedics arrived and transferred R401 to a stretcher and departed facility at 1:50 PM to Hospital per POA request for evaluation. Care Plan Initiated on 03/28/2024 documents: R401 is at high or increased risk for falls, R401 is at risk for injury from falls related to diagnosis of Dementia, Syncope, decreased physical mobility, generalized weakness, and history of falls. R401 is positive for recent and frequent falls at home. Hospital record dated 03/31/24 documents: Patient (R401) presented to emergency department via emergency medical service after fall out of wheelchair. R401 complained of left hip pain. Positive external rotation and shortening. X-ray dated 03/31/24 documents: Left Femur (hip) Findings: Comminuted intertrochanteric fracture of the proximal LEFT femur with displacement of the lesser trochanter fragment and medial angulation of the distal femur shaft. Fall prevention and management policy dated 1/2024 documents: The facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all fall is not possible, the facility will identify and evaluate those resident at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. R61 was diagnosed with Dementia, Alzheimer's disease and Anxiety. Minimal data set section GG (functional abilities and goals) dated 01/05/24 documents: manual wheelchair. R61 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident complete activity. Assistance may be provided throughout the activity or intermittently. R61's care plan dated 3/12/24 documents: actual fall. Slid to front of wheelchair and slid out of chair. Intervention: staff to encourage R61 to sit back in wheelchair, assist to reposition as indicated. On 5/14/24 at 1:01PM, V4 (restorative nurse) said, R61 was being transported in her wheelchair without leg rests. R61 was holding her feet up off the ground. R61 dropped her feet at some point. R61 had on anti-skid foot wear. R61's foot gripped on the floor leading to a fall forward out of the wheelchair. Residents who use wheelchairs for mobility should not be pushed without leg rests. Leg rests were available at the time of R61's fall. On 5/14/23 at 3:37PM, V13 (cna) said, R61 was in a wheelchair. R61 asked him to push her to the dining room. V13 said, R61 did not have any leg/foot rest on her wheelchair. R61 usually self-propel. V13 said he pushed R61 and her right foot got stuck on the floor. V13 said R61 fell forward onto the floor landing on the right side of her body. V13 said at the time of the incident, R61 reported she hurt her right side and her back. R61 laid on the floor until the emergency medical technicians arrived. Nursing note dated 03/19/24 documents: around 0745 CNA observed assisting resident (R61) to the dining room. Nurse observed resident (R61) leaning forward in the wheelchair and fell to the floor. R61 left in position, during assessment, R61 was observed with a small lump to the right side of her forehead. R61 complained on right arm pain. R61 was observed with swelling to right lower leg without shortening of extremity. 911 called. Fall event dated 03/19/24 predisposing physiological factors documents: gait imbalance, impaired memory, decrease vision or hearing; predisposing situation factors: using wheelchair and leaning. V13's witness statement dated: 03/19/24 documents: during breakfast resident (R61) asked CNA (V13) if he can push her to the dining room. While pushing R61 her foot got stuck to the floor causing R61 to fall forward. In-service dated 03/19/24 topic of education: propelling residents without foot rest. Please report to nursing when residents ask for assistance propelling. Resident may need to be evaluated for the need of leg rest. R61's [NAME] dated 3/19/24 documents: safety: staff education to only propel wheelchairs with footrest on them. Facility reportable incident dated 3/20/24 documents: Patient name: R61, describe incident/accident: while being assisted to dining area resident fell forward from the wheelchair. She (R61) complained of pain to her right arm and leg. Hospital record dated 3/19/24 documents: She (R61) leaned forward and fell out of her wheelchair. R61 has hematoma to right forehead. Fall prevention and management policy dated 1/2024 documents: The facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all fall is not possible, the facility will identify and evaluate those resident at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a system to track requests for diagnostics services to ensure timely x-ray services are provided to residents. This failure resulted in R5 being transported to the hospital after waiting over 30 hours for x-ray service and being diagnosed with multiple rib fractures for one of one reviewed for diagnostic services in a total sample of 26. Findings include: R5 was admitted to the facility on [DATE] with a diagnosis of syncope, unsteadiness on feet, orthostatic hypotension, restless leg syndrome, unspecified dementia and anxiety disorder. R5's Minimum Data Set, dated [DATE] documents brief interview for mental status is 12/15 which indicates cognitively intact. On 5/14/24 at 3:10 PM, R5 who was alert and oriented to self, place and time at time of interview said he was in his room, was putting on a jacket when he lost his balance and fell backwards hitting his left side on the heating/air conditioning wall unit and windowsill. The next day he was having pain and told staff. R5 said he was having pain in his left side 9/10. R5 pain was worse with movement and it hurt when breathing in. R5 facility reportable dated 4/6/24 documents: R5 informed nurse on duty that he fell two days ago, but did not report it, but now has pain in his left arm and left side. R5 was noted with a scrape to left side of his back. Nurse on duty notified doctor and received order for chest x-ray. Power of attorney made request for resident to go to emergency room. R5 returned on 4/8/24 with multiple rib fractures. R5's progress notes dated 4/6/24 at 12:32PM documents: Resident informed writer that he fell 2 days ago while putting on his shirt. Resident states that he didn't think it was a big deal, so he didn't tell anyone but now he is experiencing pain from his left shoulder to his abdomen. Upon assessment writer noted a scrape to left side of back. MD made aware. MD ordered chest x-ray. R5's progress notes dated 4/7/24 at 11:57AM documents: Resident alert verbally responsive. Breathing even unlabored. Denies pain and discomfort at this time. Resident and daughter inquired about estimated time of arrival of X-ray service. Writer placed call to x-ray company, informed that technician is en route. Resident and family made aware of estimated time of arrival status. Will continue plan of care. R5's progress notes dated 4/7/24 at 21:00PM documents: Per report AM nurse contacted x-ray company with estimated time of arrival and the company claimed they were en route. Resident's family concerned with timeliness of x-ray technician. Writer called x-ray services again and was unable to reach anyone. Per family's request resident sent out to local hospital. On 5/14/24 at 3:46PM, V12 (Nurse) was assigned to R5 on day he reported fall. V12 said she called the doctor who ordered an x-ray. X-ray called in and requisition completed. X-ray usually comes within 24 hours. They said they would be there the next day. V12 said she put in report but was not assigned to R5 after that day. On 5/15/24 at 12:03pm, V2(DON), said x-rays should be completed within 24 hours. If x-ray is not completed the doctor should be notified and any further orders followed. On 5/15/24 at 1257PM, V26 (Xray tech) said they received an x-ray order for R5 on 4/6/24 at 2:44PM and staff said the x-ray was to be done on 4/7/24. V26 said there was no other documentation from the facility that they called for follow up about x-ray. Technician arrived at 9:40PM on 4/7/24 but resident was already at the hospital. On 5/16/24 at 10:15AM , V32 (MD) I would expect an x-ray to be completed within 24 hours or be notified if not completed within 24 hours. I would not necessarily send the resident to hospital for pain because it's not an emergency and rib fractures are hard to see on x-rays. There really isn't much treatment. There can be pain with movement or breathing but I would not prescribe narcotics for pain. The x-ray is more of a legality, to show that fracture occurred at that time. On 5/17/24 at 10:12AM, V2(DON) said they track diagnostics services by when staff enter the order into electronic medical record under orders. Staff communicate through report when waiting for an x-ray to be conducted. Requested physician order and communication for R5's x-ray and no documentation received. R5's physician order sheets for April did not document any order for a chest xray. R5's hospital record dated 4/7/24 documents R5 arrived in emergency room at 21:54. At 22:36 Pain score of 8. Under history: R5 with mild dementia present to emergency room for evaluation of left sided back and shoulder pain. Patient states that approximately 2 days ago, he was reaching for his jacket in the middle of the night, when he slipped and fell off the bed possibly striking a shelf near his bed. Patient was able to get himself up, and nursing noticed the injuries and recommended a chest x-ray that is yet to be done. Patient states that he has been noticing increasing pain with movement on the left side and standing and finally called 911 and was brought to the emergency room. Patient denies any headache, neck pain, low back pain, chest pain, shortness of breath, cough, fevers or chills, bowel or bladder changes. Patient feels some fullness along the left upper quadrant extending from his injury in the left lower thoracic area. Patient is unaware of the pain medicine they have been given at the nursing home but states it has been only mildly helping him. Under Xray results documents: Acute left lateral seventh and eighth rib fractures. X-ray services facility in-service packet undated documents under ordering procedure: All non stat orders are performed same day, unless requested to be done another day. If the results cannot be provided same day as the procedure, you will receive them early the next day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow physician orders and implement wound care treatment for a resident with a noted stage 2 pressure sore. This affected one of three residents (R1) reviewed for pressure sores. This failure resulted in R1's wound worsening requiring debridement and progressing to a stage 3. Findings include: R1 face sheet shows R1 has diagnosis of weakness, diabetes mellitus. On 1/9/23 at 1:00pm V5 (director of nursing) presents document dated 9/6/23 denoting R1 skin color, texture, turgor normal. No rashes or lesions. On 1/9/23 at 11:13am V9 (wound care coordinator) said the nurse documented that R1 was admitted on [DATE] with a wound, V9 said when she assessed R1 on 9/11/23 R1 did not have any skin issue, R1 skin was intact. V9 said she can't explain the documentation of the nurse. V9 said on 9/16/23 the floor nurse informed her that R1 had skin issue on her tail bone. V9 said the floor nurse got an order for hydrocolloid. V9 said on 9/18/23 she assessed R1 and R1 had a small stage 2 pressure sore. V9 described the tissue was pink and the wound was superficial. V9 said the hydrocolloid treatment continued. V9 said hydrocolloid was appropriate for the stage 2. V9 said R1 was seen by the wound doctor on 9/22/23 and the wound doctor ordered zinc, medi-honey, and calcium alginate and foam dressing. V9 said hydrocolloid is used for protection of the wound. Medi-honey is used for debridement. R1 MAR (Medication Administration record) TAR (Treatment administration record), POS) physician order sheet) and wound care progress notes reviewed with V9, V9 said she don't see the order for zinc, V9 said she don't see the order for benzoin, V9 said she don't see an order for calcium alginate. V9 said she is responsible transcribing the wound care treatment orders when she receives them from the wound care physician. V9 explained she don't know what happened with transcribing the treatment order for zinc, calcium alginate, and benzoin. V9 said she was doing R1 wound treatment daily when she worked, V9 was asked how she ensured that she verified and implement the correct treatment orders daily if they were not listed on R1's TAR (treatment administration record) and R1's POS (physician order sheet). V9 did not give response. V9 said calcium alginate is used for absorption of drainage but allow for moisture to remain, V9 said calcium alginate also debrides the wound. R1 wound assessment reviewed with V9, V9 was asked what the treatment plan was when the wound was identified on 9/11/23, V9 said the nurse got order for hydrocolloid, R1 POS reviewed with V9 denoting hydrocolloid was ordered on 9/18/23, V9 was ask, what the treatment plan was when the wound was identified on 9/1123, V9 said hydrocolloid. R1 TAR reviewed with V9, V9 verified that her initials were listed once on R1 TAR on 9/18/23. V9 was asked how she ensured that other nursing staff implemented the correct wound treatment to R1, if R1 POS and TAR does not have all the wound treatment orders listed. V9 said she don't know what benzoin was. V9 said the electronic record (PCC) is the only place she documents wound treatment administration. V9 said all orders should be documented on the physician order sheet (POS). Upon exit of this survey the facility failed to present supporting orders/documentation denoting that a wound treatment plan was initiated for R1 on 9/11/23 when the pressure ulcer was identified. On 1/9/23 at 1:16PM V25 (wound care physician) said the facility should follow wound care treatment orders as prescribed. V25 said calcium alginate is used for wound drainage. R1 admission assessment dated [DATE] denotes R1 has a wound. There is no description of wound, no measurements of the wound, no location of the wound. V5 (Director of Nursing) name is identified as the person that signed/completed the admission assessment for R1. On 1/9/23 V5 (director of nursing) presents document dated 8/26/23 denoting R1 had a superficial wound to bilateral gluteal area, prior to admission, at 1:00pm V5 presents document dated 9/6/23 that R1 skin color, texture, turgor normal. No rashes or lesions. On 1/10/24 V5 (Director of Nursing) denied completing R1 admission assessment, V5 said she may have filled in the information that was missing. V5 said she should not electronically sign documents that she did not complete. V5 said she don't know what missing information that she filled into R1 admission assessment. R1 wound assessment detail report dated 9/18/23 denotes in-part date identified 9/11/23, pressure alteration, present on admission, clinical stage 2, pink or red non granulating 100%, wound edges distinct and attached, size 1.30 centimeters (cm) x 1.30cm x 0.10cm (L x W x D) (length x width x depth) area 1.69cm squared. Wound bed is clean at this time. Wound care will continue to treat and monitor. Reassessment to be completed in one week. Wound MD is to follow this Friday. R1 wound assessment detail report dated 9/26/23 denotes in-part date identified 9/11/23, pressure alteration, present on admission, clinical stage 2, pink or red non granulating 80%, slough loosely adherent 20%, wound edges distinct and attached, size 5.50 centimeters (cm) x 4.00cm x 0.10cm (L x W x D) (length x width x depth) area 22.00cm squared. Wound has increased in size and tissue is declining. Wound care will continue to treat and monitor. Reassessment to be completed in one week. R1 wound assessment detail report dated 10/4/23 denotes in-part date identified 9/11/23, pressure alteration, present on admission, clinical stage 2, pink or red non granulating 30%, slough loosely adherent 60%, necrotic soft 10%, wound edges distinct and attached, size 7.00 centimeters (cm) x 8.00cm x 0.20cm (L x W x D) (length x width x depth) area 56.00cm squared. Wound has increased in size and tissue is declining. Wound care will continue to treat and monitor. Reassessment to be completed in one week. R1 wound care progress notes completed by V25 (wound care doctor) denotes in-part pressure ulcer, sacral pressure ulcer, stage 2, treatment the plan for the pressure ulcer is to clean the aera with normal saline and the peri wound area with wound cleanser. Peri-wound skin treatment: benzoin, zinc oxide 20%. Wound filler: Medi honey. Primary dressing: calcium alginate. Secondary dressing: foam. This treatment will be done 3 times per week as needed. Today's treatment will be performed by the wound care team and other care perform by staff and the staff of the facility. The pressure ulcer was not debrided. Plan of care discussed with facility staff and patient. R1 POS (physician Order sheet) dated 9/16/23 denotes orders for cleanse sacral ulcer with NS (normal saline), pat dry, and apply hydrocolloid dressing Q (every) 72 hours and PRN (as needed) for sacral ulcer. Order date 9/16/23, start date 9/16/23. R1 POS (physician Order sheet) dated 9/26/23 denotes orders for cleanse sacral ulcer with NS (normal saline), pat dry, and apply medi-honey with foam dressing, every 72 hours for sacral ulcer. Order date 9/26/23, start date 9/26/23. Review of R1 POS there is no wound care treatment orders noted prior to 9/16/23, although R1 wound assessment details denotes R1 wound was identified on 9/11/23. R1 POS (physician order sheet) does not denote orders for calcium alginate, R1 POS does not denote orders for zinc 20%, R1 POS does not denote orders for benzoin. R1 POS denotes R1 Medi-honey treatment was ordered on 9/26/23, four days after ordered by the wound care doctor. R1 TAR (treatment administration record) for September 2023 and October 2023, there is no treatment documented for calcium alginate, there is no treatment documented for zinc 20%, there is no treatment documented for benzoin. Facility policy titled skin prevention dated 1/2023 denotes in-part all residents will receive appropriate care to decrease the risk of skin breakdown. The nursing department will review all new admissions/readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. Facility policy titled physician orders dated 2/203 denotes in-part drugs will be administered only upon a clean, complete and signed order of a person lawfully authorized to prescribe. Documentation of the medication order: each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet and the Medication Administration Record (MAR) or Treatment Administration Record (TAR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to have an effective plan to monitor/supervise resident identified to be high risk for falls This affected one of three residents (R1) reviewed for falls and fall prevention. This failure resulted in R1 falling from bed and sustaining a non-displaced transverse fractures demonstrated on the right side at the C6 and C7 levels. Findings include: R1 has diagnosis including but not limited to Displaced Fracture of Seventh Cervical Vertebra, Difficulty in Walking, Fracture of Neck, Dysphagia, Cerebral Infarction, Hypertension, Dementia, and Depression. R1's cognitive assessment dated [DATE] indicates R1 is severely impaired. R1's bowel and bladder assessment dated [DATE] states R1 is always incontinent of urine. R1's functional status states she requires extensive assistance with bed mobility, dressing, and personal hygiene. R1 is total dependent on staff for toileting assistance. R1 was initially admitted to the facility on [DATE]. On 9/5/23 at 1:26PM V3, Certified Nursing Assistant (CNA), said I kind of know who is at risk for falls from working here. On 9/6/23 at 5:19PM V15, Nurse, said I don't remember R1. The surveyor read off portions of the admission document to V15. V15 could not remember R1 specifically. V15 said we used to use leaves for all risk people, but no longer. V15 said if we get an admission in the evening, often times we don't know about it ahead of time, and we are hunting for floor mats and other equipment needed. V15 said CNAs are verbally told who is a fall risk. V15 said the night nurse would be responsible to notify the night CNA, because second shift ends before the night shift arrives. On 9/6/23 at 10:52AM V5, Restorative Nurse, said I was on vacation from 7/3-7/11/23. V5 said I assess a patient for abilities I document on the form or progress note. V5 said I don't have any documentation prior to 7/5/23 for R1's transfer status. On 9/6/23 at 4:34PM V13, CNA, said on 7/4/23 the nurse called me to get R1 up, I was not the first to see R1 on the floor. V13 said the nurse called me while I was in another room. V13 said the nurse, another aid, and I got R1 off the floor using the mechanical lift. V13 said I had not changed R1, yet. V13 said no one gave me report when I started my shift. V13 said I knew she was a new patient, but I didn't know she was a fall risk. V13 said if I had known R1 was a fall risk, I would have checked R1 often. V13 said R1 is incontinent of bowel and bladder. V13 said I don't know if the new company uses a fall program. On 9/6/23 at 4:48PM V14, CNA, said we know who is a fall risk from working there and people talking. V14 said we do not always get report from the nurses at the start of a shift. V14 said it is possible a new admission comes in and no one tells us about them. On 9/6/23 at 10:04AM V2, LPN, said the Aid reported R1 was on the floor along the bed. When I entered the room, I saw R1 along the side of the bed on the floor. V2 said R1 said she was trying to get up out of bed. V2 said R1 had just been admitted . V2 said I had not worked with R1 and I was not aware of her behaviors. Report was that she was alert and oriented x 2-3, able to make her needs known, and she was long term. V2 said R1 had some confusion, dementia and behaviors. V2 said R1's bed was lower, I can't recall how low. V2 said R1's bed did not go to the floor it was not on the floor. On 9/6/23 at 1:30PM V12, Wound Nurse, said the day R1 fell one of her feet might have been hanging from the bed. V12 said R1 was not able to turn side to side when she first came in. On 9/6/23 at 1:23PM V17, Former DON, said she investigated R1's fall on 7/4/23. V17 said R1 was trying to reposition herself in the bed. V17 said R1 had progression in dementia and her poor safety awareness was the root cause of the fall. V17 said R1 had only been at the facility for a few days. V17 said I am not sure if R1 had a fall prior to 7/4/23. Review of 7/2/23 Physical Therapy evaluation documents impaired strength to legs. Incident report reviewed, report has no root cause documented and none in the progress notes. R1's admission Clinical Evaluation dated 7/1/23 includes Risk Alerts Falls. Fall risk assessment dated [DATE] states R1 is unable to independently come to standing position and has decreased muscle coordination and a final score of 14. R1's care plan initiated on 7/1/23 states R1 is at high risk for falls. Progress Notes dated 7/4/23 at 11:55PM state R1 had an unwitnessed fall. Progress notes dated 7/5/23 document at 9:00AM the family requested R1 be sent to the hospital for evaluation. R1's CT Cervical Spine dated 7/5/23 reads Findings: Probably non-displaced transverse fractures demonstrated on the right side at the C6 and C7 levels. R1's hospital History and Physical dated 7/5/23 states closed fracture of C6 and C7. Suspected to be due to trauma from fall. The facility Fall Prevention and Management policy dated 1/2023 states the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. A score of 10 or greater indicates a high risk