Based on observation, interview, and record review, the facility failed to ensure resident safety after a transfer and failed to keep a resident free from injury for one of three residents (R1) reviewed for accidents/injuries in a sample of four. This failure resulted in R1 sustaining pain, bruising and a hospital visit with fractures to the left ankle and foot. Findings include: The facility's undated Residents' Rights for People in Long-Term Care Facilities documents Your rights to safety: The facility must provide services to keep your physical and mental health, at their highest practical levels. The facility's Resident Accident/Incident Policy, revised 5/12/15, documents It is the Policy of (named facility) to provide a safe environment for all residents. We understand there will be a time when our best efforts will not be enough. Accidents will happen. Residents will fall. The facility's Fall Policy and Procedure, revised 1/2/19, documents It is the Policy of (named facility) to provide an environment conducive to reducing risk for falls. (Named facility) provides interventions to reduce risk factors for falling but cannot guarantee or maintain a fall-free environment. R1's current clinical record documents R1 is alert and oriented times three (person, place, and time), dependent on staff for all ADLs (Activities of Daily Living) except eating, utilizes a wheelchair, and has diagnoses including but not limited to Dementia with agitation, Peripheral Vertigo, Alzheimer's Disease, Hypertension, Congestive Heart Failure, Anxiety, and Muscle weakness (generalized). R1's Accident/Incident Report, dated, 2/28/25 at 6:15pm, documents R1 had an unobserved fall from a (reclining) wheelchair while in her room. R1's Progress note, dated 2/28/25, documents CNA (Certified Nursing Assistant/V8) notified staff that he went to get bed linens and when (V8) came back to room (R1) was on the floor lying on her side. On 3/26/25, at 1:14pm, R1 was resting in a (reclining) chair in her room. On 3/27/25, at 11:06am, V8 CNA stated I took (R1) to her room then went to the linen closet to put her to bed. When I came back, she had fallen out of the (reclining wheelchair). All four wheels were in the air. She was against the mattress which was leaning on the wall. R1's butt (buttocks) was on the foot pedal and rest of her body was up against the mattress against the wall. The chair fell forward. (R1's) (reclining chair) was in the upright position. I think if I would have reclined it (the chair), I could have prevented it (R1's fall). R1's current Care plan documents R1 is totally dependent on staff for transferring and is at risk for falls related to decline in health. This Care plan includes an intervention dated 2/12/25 for nursing staff to ensure R1's (reclining)wheelchair is reclined when sitting in (reclining) wheelchair and not eating. R1's Skin Tear/Bruise of Unknown Origin Investigation, dated 3/7/25 at 4:15pm, documents R1's left lower leg foot/ankle swollen and bruised. List of resident equipment in use: wheelchair/(reclining) wheelchair/mechanical lift. Internal Risk Factors identified as Mobility deficit or immobility, History of fall and partial falls, and restless behavior. R1's Unusual Occurrence Report Form, dated 3/7/25, documents R1 with complaints of pain to the bridge of her left foot. The bedside X-ray Results for R1, dated 3/7/25, documents there is an oblique fracture of the distal third of the fibula. Impression: Non articular fracture of the distal fibula. R1's Progress note, dated 3/8/25, documents Resident showing signs of excruciating pain and discomfort. Per Nursing judgement, this nurse made an educated decision to send resident out to ER (Emergency Room) to be further evaluated. Resident agrees with treatment plan stating her 'foot hurts really bad.' The local hospital radiology report of R1's left ankle x-ray, dated 3/8/25, documents: History: Left ankle pain after falling out of chair. Impression: 1. Acute nondisplaced fracture of the distal fibula. 2. Acute displaced fracture of the fourth metatarsal neck. 3. Acute nondisplaced fractures of the base of the second and third metatarsals. R1's Hospital After Visit Summary, dated 3/8/25, documents Reason for Visit: Fall; Ankle Injury. The facility's Final Report to the State Agency for R1, dated 3/14/25, documents resident (R1) subsequently went out to hospital on 3/8/25 related to increased swelling observed by RN (Registered Nurse). Imaging showed the distal fibula fracture as well as several metatarsals. Resident (R1) returned to the facility with lower extremity in protective wrap. An appointment is scheduled with (Orthopedics) on the 17th of this month. An extensive investigation was complete per the Administrator with staff interviews and review of the cameras. On 3/27/25, at 2:10pm, R1 was transferred into bed via mechanical lift. Staff removed the splint/boot from her left foot/ankle. R1 was now lying in bed with a bandage noted to her left foot/ankle. At this time R1 stated the following: It happened when I was in a chair. I turned my head because I heard someone, I thought I knew. When I turned back, I fell to the right and out of my chair. My left foot hit the wall. It hurt. Four staff got me back up. It was a few days later that they sent me out to the hospital and found out it was fractured. On 3/28/25, at 1:50pm, V15 R1's Family Member stated When I asked (R1) how she hurt her foot she told me the same thing. She had said that she was in a chair, heard people talking to her, turned to look towards them and fell out of the chair. R1's Progress note, dated 3/10/25 and signed by V19 Nurse Practitioner/NP, documents INTERVAL HISTORY: Pt (patient) is up in her WC (wheelchair). She has some pain to her LLE (left lower extremity). Was noted to be sore, bruised and swollen. Did have an XR (x-ray) that showed: Closed left ankle fracture and multiple closed fractures on metatarsal bone of left foot. Splint in place and referred to podiatry. On 4/1/25, at 11:28am, V19 Nurse Practitioner/NP confirmed that (R1's) fracture is most likely from a previous fall. On 4/1/25, at 1:34pm, V2 Director of Nursing/DON stated, I was notified about (R1's) foot when (V15 R1's Family Member) came in and asked about it on Friday March 7th. I went to (R1's) room. I saw edema, significant bruising to ankle, top of foot and posterior aspect of foot/ankle. On 3/28/25, at 2:50pm, V1 Administrator confirmed that R1 did have a fall on 2/28/25 and confirmed R1's fractures to her ankle/foot. As of 3/28/25, R1's medical record did not document any further falls/accidents/incidents between R1's fall on 2/28/25 and 3/7/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to transfer a resident with the required mechanical lift, for one of three residents (R1) reviewed for falls in a sample of 3. This failure resulted in R1 falling twice and during the second fall sustaining a periprosthetic distal left femur fracture, ongoing pain, and psychosocial fear of being transferred with a mechanical lift. FINDINGS INCLUDE: The facility policy, Fall Policy and Procedure directs staff, It is the policy of (the facility) to provide an environment conducive to reducing risk for falls. (The facility) provides interventions to reduce risk factors for falling .Should the resident be observed sitting on the floor or being assisted by staff to sit down on the floor, the nurse will be notified and a fall report will be completed R1's current facility Face Sheet documents that R1 was admitted to the facility on [DATE] after a fall with a Left Hip Fracture. This same form includes the following diagnoses: Cerebral Palsy, Blindness of One Eye, History of Cerebral Infarction, Paraplegia, Depression with Psychotic Features and Anxiety. R1's (current) Care Plan, dated 6/16/2023 includes the following Focus Areas: (R1) is at risk for falls related to history of cerebral palsy, left hip fracture and left-sided paraplegia. Also included are the following Interventions: Transfers: (R1) requires extensive assistance by two staff to move between surfaces using a (mechanical) lift. R1's Minimum Data Set Assessment, dated 11/14/2024 documents, ADL's (Activities of Daily Living): Impairment on one side of lower extremity; requires use of wheel chair; requires substantial/max (maximum) assistance for bathing, dressing, and bed mobility and is dependent for all transfers. Requires extensive assistance of 2 staff members and (mechanical) lift for all transfers. R1's Fall Risk Evaluation, dated 11/24/2024 documents, One to two falls past 3 months, Intermittent confusion, Chairbound/Incontinent, 1-2 Predisposing Diseases, Gait/Balance- not able to perform function and Takes 1-2 (High Risk) Medications. Risk For Falls: (R1) is at risk for falls. R1's Nursing Progress Notes, dated 1/9/2025 at 3:51 P.M. document, CNA (Certified Nursing Assistant) was behind (R1) holding (R1) at the shower bar while attempting to transfer from (R1's) w/c (wheelchair) to the shower chair, for a shower. (R1) thought her phone had fell out of her belongings onto the floor and turned around suddenly and fell on her buttocks. No apparent injury. The facility Fall Investigation form, dated 1/9/2025 documents,(V5/Certified Nursing Assistant) was behind (R1) holding her while (R1) held shower bar. (R1) jerked around and fell on her buttocks. Recommendations/Interventions: Staff Member (V5/Certified Nursing Assistant) was educated on (correct) transfer for (R1) and the use of a shower bed. R1's Nursing Progress Notes, dated 1/24/2025 at 3:48 P.M. document, This Nurse (V4/Registered Nurse) had a conversation with (V6/Certified Nursing Assistant) (who) stated (R1) only told me her leg hurt and that (R1) didn't didn't know why. (V6/Certified Nursing Assistant) stated I transferred (R1) and (R1) started shaking and buckled and I lowered (R1) to the floor. There was no fall, I lowered (R1) to the floor. R1's Nursing Progress Notes, dated 1/24/2025 at 4:00 P.M. document, Certified Nursing Assistant came to Nurses' Desk and (stated) (R1) needed something for pain. (Nurse) went to (R1's) room and asked (R1) what was wrong and what hurt. (R1) stated her L (left) upper thigh hurt. (I) asked (R1) what type of pain, aching, sharp and (R1) replied deep aching. (Nurse) gave (R1) (Acetaminophen) (Analgesic) at (3:50 P.M.). R1's Nursing Progress Notes, dated 1/24/2025 at 6:41 (P.M.) document, Upon coming on shift, (V4/Registered Nurse) reported that (V6/Certified Nursing Assistant/CNA) had lowered (R1) to the floor. CNA indicated that (R1) is complaining of pain in the left leg, describing it as excruciating. (R1) also stated that she is unable to move her left leg. Upon assessment, the nurse observed swelling to (R1's) right ankle. The physician has been notified of the situation. R1's Nursing Progress Notes, dated 1/24/2025 at 6:56 P.M. document, MD (Medical Doctor) states send (R1) to the ER (Emergency Room). (R1) to be further evaluated. The facility Fall Investigation form, dated 1/24/2025 documents, (R1) stated her left thigh hurt and she didn't know why and (R1) had pain when nurse tried to lift her leg. Later, (V6/CNA) stated she transferred (R1) and (R1) began shaking and buckled and (V6) lowered (R1) to the floor. Recommendations/Interventions: (V6) was disciplined and all the other staff will be inserviced to use (mechanical) lift only with (R1). R1's (hospital) History and Physical documents, admission date: 1/25/25. (R1) with past medical history for depression with anxiety, seizure disorder, and left-sided hemiplegia due to cerebral palsy who presented to the hospital after a fall at (facility). (R1) was reportedly being transferred by the staff when (R1) was dropped, landing on her left side. Imaging in the ED (Emergency Department) showed questionable left hip injury as well as a distal periprosthetic femur fracture on the left. (R1) reports significant discomfort in her left leg at this time, more in the distal thigh but has some pain in the hip. ASSESSMENT AND PLAN: Closed fracture of distal end of femur. Orthopedic surgery has been consulted. On 2/10/2025 at 10:45 A.M., R1 was seated in a wheel chair in the (facility) Dining/Activity Room with other residents, at a table for coffee and donuts. (R1) recalls falling two times, once when staff dropped me. R1 becomes visibly upset, crying when talking of incident. Repeats over and over, I hurt. I'm afraid of the lift. Refused to answer further questions surrounding incidents. On 2/10/2025 at 10:59 A.M., V4/Registered Nurse (RN) stated, I have been a nurse here for the past ten years and three weeks. (R1) had a history of a previous fall with a fracture, left-sided paraplegia, and a history of cerebral palsy. (R1) was supposed to be a two person, lift for all transfers. V6/Certified Nursing Assistant (CNA) came to me and asked if (R1) had anything for pain. (V6/CNA) said (R1's) leg hurt. I went to see (R1) and she told me that (V6/CNA) had dropped her and hurt her leg. When I questioned (V6/CNA), she told me she was transferring (R1) by herself from the bed to (R1's) wheelchair and (R1's) leg buckled and (V6/CNA) lowered (R1) to the floor. (V6/CNA) kept repeating that she only lowered (R1) to the floor. I didn't do a fall report right away, call the doctor, or R1's family or the DON (V2/Director of Nurses). I didn't consider it a fall. It wasn't until later that (V2/DON) told all of us that even when you lower someone to the floor, it's considered a fall. (R1) has always been a (mechanical) lift for all transfers. (V6/CNA) should not have been trying to transfer (R1) by herself. On 2/10/2025 at 12:25 P.M., V3/Care Plan Coordinator stated she was responsible for all the facility fall investigations. States (R1) is at risk for falls due to history of CP (Cerebral Palsy), paraplegia and blindness to (the) left side and history of falls with a fracture. States (R1) does not stand and has been a (mechanical) lift for the past two years. States facility policy is for all mechanical lift transfers to be performed with two staff members present. States (R1's) care plan addressed (R1's) interventions including the use of a mechanical lift for all transfers. States (R1's) facility care cards, addressed (R1's) need for a mechanical lift for all transfers. States care cards are used to inform the CNAs (Certified Nursing Assistants) what specific care each resident requires. States she investigated both of (R1's) falls in January. States on 1/9/25 at 3:00 PM, (V5/CNA) was attempting to transfer (R1) by herself, without using a mechanical lift, from (R1's) wheel chair to a shower chair. Confirmed that (R1) fell on her buttocks. States (V5/CNA) was educated on the need to use a mechanical lift to transfer (R1) from her wheelchair onto the facility shower bed, for (R1) to receive a shower. Also confirms that (R1) fell again on 1/24/25 at 3:40 PM when (V6/CNA) transferred (R1) by herself, without the use of a mechanical lift from (R1's) bed to (R1's) wheelchair, when (R1's) leg gave out and she lowered (R1) to the floor. States (V6/CNA) was disciplined for failure to use a mechanical lift and another staff assistance for all of (R1's) transfers and all other nursing staff were educated on the need to use a mechanical lift to transfer (R1). On 2/10/2025 at 1:12 P.M., V5/Certified Nursing Assistant (CNA) confirmed on 1/9/25 she attempted to transfer (R1) from the wheelchair to a shower chair, while in the shower room. (V5/CNA) states (R1) thought she had dropped her phone and turned around suddenly to look for it and fell onto (R1's) buttocks. (V5/CNA) states she didn't know she was supposed to transfer (R1) at all times with a mechanical lift, states she hadn't worked with (R1) very often. On 2/10/2025 at 1:18 P.M., V6/Certified Nursing Assistant verified on 1/24/25 she attempted to transfer (R1) from the bed into (R1's) wheelchair, when (R1's) leg gave out and she lowered (R1) to the floor. (V6/CNA) states she wasn't aware she was supposed to transfer (R1) with a mechanical lift and additional staff assistance, at all times. On 2/10/2025 at 1:26 P.M., V7 and V8/Certified Nursing Assistants prepared to transfer (R1) from the wheelchair to bed for incontinence care via a mechanical lift. (R1) began yelling out and was tearful with any movement of her left leg.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to conduct a resident assessment to determine the resident's degree of mobility, physical impairment and the proper transfer method needed once a resident experienced increased weakness. The facility also failed to maintain an adequate working electrical supply to adjust an electric bed into the lowest position prior to a transfer for one resident (R9) and failed to implement appropriate fall interventions for one resident (R8.) These failures affect two of three residents (R8, R9) reviewed for falls in the sample of 27. These failures resulted in R9 losing grip of the sit-to-stand mechanical lift handles and falling to the floor, sustaining a coccyx fracture and severe pain that required hospitalization. B. Based on observation, interview, and record review the facility failed to assess the smoking safety yearly for one of five residents (R40) reviewed for smoking in the sample of 27. Findings include: a.) The facility's Job Description for CNA's (Certified Nursing Assistants), undated, documents Illustrative Examples of Work: Care delivery to include, but not limited to: Bathing a minimum of two times weekly, daily oral hygiene, shaving, changing clothes, nail care, toileting feeding, ambulating, transferring, room care, hair care. Recognizing and reporting changes in condition to the nurse (example: health problems, eating problems, changes in skin or incontinence behavioral problems, unstable vital signs.) Maintain a safe environment for the residents and other staff. Follow safety practices (example: keeping resident areas hazard free, follow good body mechanics, wear proper footwear, use lifting devices according to manufacturer's directs, wear gait belt, etcetera.). General Employee Guidelines: Immediately report defective equipment, hazardous conditions, or supply shortages. The facility's Fall Policy and Procedure, dated 1/2/2019, documents It is the Policy of (the facility) to provide an environment conducive to reducing risk for falls. (The facility) provides interventions to reduce risk factors for filling but cannot guarantee or maintain a fall-free environment. The facility's Transfer Between Surfaces policy, dated 3/2000, documents Purpose: To improve or maintain the resident's self-performance in moving between surfaces or planes either with or without assistive devices. Procedure: 1. Explain and demonstrate procedure. 5. Bed should be flat and level with wheelchair seat. The facility's Fall Prevention Practice, dated 1/10/2016, documents Below is a list of things that can help reduce the risk for falls: 8. Report changes in mental status to nurse immediately. 1. R9's admission Record documents R9 is a [AGE] year-old male admitted to (the facility) on 5/14/2012 with the following, but not limited to, diagnoses: Chronic Obstructive Pulmonary Disease, Difficulty in walking, Frontotemporal Neurocognitive Disorder, Dementia, Schizoaffective Disorder, Extrapyramidal and Movement Disorder, and Cerebral Infarction. R9's Minimum Data Set (MDS) assessment dated [DATE], documents R9 has severe cognitive impairment, and requires substantial assistance for activities of daily living, toileting, and transfers. R9's current Care Plan documents, (R9) has the potential for falls due to increased weakness. The facility's Maintenance Work Order dated 9/19/24 and signed by V7/CNA, documents R9's room had no electricity. R9's Progress Note, dated 9/19/24 and signed by V15/RN (Registered Nurse), documents (R9) was observed on the floor, lying on right side. Per two aides (Identified as V8/CNA (Certified Nursing Assistant) and (V9/CNA), they were attempting to get (R9) into bed. After a couple minutes, it was indicated that (R9) was to be moved back into chair due to the bed being unavailable for use. Throughout all of this, (R9) was in a mechanical stand lift and was already up at the highest position. Per (V8 and V9), (R9) began to drift down. (V8 and V9) stated that they pulled chair under (R9) but at that point (R9) was too low to get into his chair. Then (V8 and V9) stated that (R9) quickly slid through the straps due to him lifting his arms up, where (R9) then hit the floor at fast and unexpected speed where (V8 and V9) were unable to slowly lower (R9). Different reports of if (R9) hit head or not, so per the physician, we (the facility) called emergency services to send (R9) out to the emergency room to be evaluated due to nature of fall. Per (V8 and V9) (R9) was lethargic. No signs of lethargy when this nurse assessed (R9). During assessment, (R9) stated that he was in extreme pain on right side of arm. R9's Electronic Medical Record does not include evidence of a nursing assessment being performed when R9 was lethargic prior to be transferred from the wheelchair. R9's Local Emergency Record, dated 9/19/24, documents CT (Computed Tomography) pelvis for bone detail without contrast final result: Impression:1. Acute or subacute mildly displaced comminuted inferior coccyx fracture. This same form documents Clinical Impression: Fall, Urinary Tract Infection, and Hyponatremia (low sodium level.) On 10/06/24 at 9:02 AM R9 was in self-propelling wheelchair around R9's room. R9 had nonskid socks on. R9 was unable to answer questions appropriately at this time. On 10/7/24 at 12:04 PM V8/CNA stated, (V9/CNA) and I were transferring (R9) from his wheelchair to the bed with a mechanical stand lift machine. (R9) was weak when (V9) and I were lifting him, so (V9) and I tried to get (R9) to the bed quickly. When (V9) and I attempted to transfer (R9) to the bed we realized the bed was too high. I then tried to use the controller to lower the bed while (R9) was trying to hold on and slipping from the sit-to-stand machine at the same time. I realized the controller was not working to the bed, so (V9) and I attempted to turn him back around and put him in the wheelchair. By that time (R9) had let go of the sit-to stand and had fell to the ground. V8 verified at this time, that she should have not attempted to transfer (V8) when she realized he was weak and should have ensured the bed was working and in the proper position prior to transferring R9. On 10/7/24 at 12:14 PM V9/CNA stated, (R9) was not a resident on my group the night of 9/19/24, but I was asked to help lay (R9) down. (R9) had been outside at a party, and when he came inside, (R9) was found lopped over the side of his wheelchair in the television room. (V15/RN) called (V8/CNA) and I up to the nurse's desk and asked for us to lay (R9) down. I pushed (R9) to his room with (V8). I asked (V8) how she wanted to transfer (R9) since (R9) seemed weak and was lopped over. (V8) just stated we would transfer (R9) with the stand mechanical lift and get him to his bed. (V8) and I strapped (R9) to the mechanical stand lift machine and started lifting (V8) up in the air. As (V8) and I were lifting him up, (R9) started slipping and was barely hanging on to the (stand lift machine.) (V8) and I attempted to hurry and put (R9) in bed before (R9) fell just to notice the bed was too high. (V8) and I tried to use the controller to lower the bed and the controller wasn't working. (V8) and I attempted to turn (R9) back around to get (R9) in his wheelchair, but (R9) kept getting lower and lower and then let go of the (hand bars of the mechanical stand lift) machine. When (R9) let go of the (stand lift machine) (R9) fell quickly to the ground. If (R9) was on my group that night, I would have not transferred him to the bed when he was visibly weak. I would have gone and notified (R9's) nurse to have (R9) assessed. I should have done that anyway, but I felt like that was (V8's) responsibility. V9 verified she should have notified R9's nurse prior to transferring R9 when R9 was lethargic and should have ensured the bed was working and in the proper position prior to transferring R9 to the bed. On 10/7/2024 at 12:30 PM V6/Maintenance Assistant stated, I get work orders for no electricity all the time for rooms. The staff will move the resident's beds and hit the plug, which breaks a prong off in the outlet. When the staff went to plug the bed back in, the plug-in hits the prong and blows the circuit breaker. I received the work order for (R9) not having electricity in his room on 9/20/24. The staff laid it on my desk on 9/19/24, but I don't usually get to work orders in the same day, it's always the next day I am at the facility. No staff member got ahold of me to let me know (R9) did not have electricity in his room on 9/19/24. On 10/7/24 at 12:47 PM V7/CNA stated, I filled out a work order on 9/19/24 around 2:30 PM regarding (R9) not having electricity in his room. (R9's) television was not working. I put the work order on (V6/Maintenance Assistance) desk. I did not tell anyone else or try to get ahold of (V6) to fix it right then. On 10/8/24 at 1PM V2/Director of Nursing stated, If any staff notices a change in condition with a resident, they should immediately notify the nurse prior to transferring especially if the resident seems weaker. Also, the staff should have everything positioned correctly prior to transferring any resident. V2 verified no nursing assessment had been performed prior to V8/CNA and V9/CNA transferring R9 from his wheelchair. On 10/8/24 at 1:09 PM V3/Assistant Director of Nursing stated Staff should go to the nurse or myself prior to transferring a resident if they notice a change in the resident's condition or if they notice the resident is weaker. They should never transfer someone to a bed with the bed in high position, they should always ensure the bed is at appropriate position prior to transferring. 2. R8's Fall Investigation Worksheet/Worksheet, dated 5/25/24 at 8:56 pm, documents that R8 slid out of the wheelchair in R8's room, while transferring self to bed. The Worksheet documents no injuries and fall interventions for a gripper pad to be placed in R8's wheelchair and to utilize a nightlight. R8's Fall Investigation Worksheet, dated 7/1/24 at 4:00 pm, documents a fall in R8's bathroom. The Worksheet documents that R8's decision making is impaired and has unsteady gait. The Worksheet describes that R8 hit the side of R8's head on R8's bathroom door jamb/frame while trying to get up from the toilet. The Worksheet documents no injuries and fall interventions for staff to intervene when they see her going down the hall and ask her is she needs to go to the bathroom and take her as much as possible. R8's Fall Investigation Worksheet, dated 7/27/24 at 3:00 pm, documents a fall from R8's wheelchair, in R8's room. The Worksheet documents that R8 has impaired memory, impaired decision making and is impaired physically. The Worksheet documents no injuries and fall interventions to educate R8 on the proper use of R8's call light. R8's Fall Investigation Worksheet, dated 9/8/24 at 10:08 am, documents a fall from R8's wheelchair in R8's room. The Worksheet documents no injuries and that R8's gripper pad be replaced in R8's wheelchair. On 10/8/24 at 12:50 pm, V2 (Director of Nursing) stated (R8) is confused and self transfers a lot. (R8) is frequently taking herself to the bathroom and she always slides to the end of R8's wheelchair seat all the time too. On the first fall, we put a gripper pad on (R8's) wheelchair to help to grip (R8) in the wheelchair but (R8) does not like it on there and removes it all the time. R8's MDS (Minimum Data Set) documents that (R8's) cognition score is ten out of fifteen, which is moderately impaired. We have educated (R8) and we just changed (R8's) gripper pad again. Now that I think about it, we probably should use some different interventions since (R8) is confused and keeps removing the gripper pad from (R8's) wheelchair. We do not have (R8) on a toileting schedule. b.) On 10/7/24 at 9:15 AM, R40 was sitting in front of the facility in his wheelchair with two other residents and had just finished smoking a cigarette. There were no staff present for supervision. On 10/8/24 at 11:55 AM, V4/MDS/Minimum Data Set Coordinator stated that R40 is an independent smoker and does not need to be monitored. On 10/8/24 at 2:20 PM, V2/Director of Nursing stated that the smoking assessments are to be done at least yearly by V14/Activity Director. R40's Face Sheet documents R40 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Mild Cognitive Impairment, Emphysema, and Chronic Obstructive Pulmonary Disease. R40's Care Plan dated 3/23/22 documents (R40) is an independent smoker. The Resident Smoking List for October 2024 documents that R40 is an independent smoker. R40's facility Smoking -Safety Screen dated 3/1/23 at 3:23 PM, documents that R40 has cognition loss, dexterity problems, is an independent smoker, keeps his own smoking materials, and lights his own cigarettes. The Smoking Safety Policy and Procedure revised 7/18/2019 documents Policy In order to provide the residents of (the facility) the opportunity to use tobacco products and do so in a safe environment and manner, the following procedures/rules/regulations shall be followed by all residents. Procedure Those that wish to use tobacco products will be assessed upon admission, yearly, and as needed as to the resident ability to smoke safely and to ascertain other needs the resident may have in which using tobacco products would be an issue, i.e. (example), ability to manage/ budget tobacco products. Based upon this assessment the resident will be placed in one of three groups as described below (full independence, managed independence, or supervised). A copy of the rules and regulations pertaining to smoking is given to each resident and further discussed with the SSA (Social Service Assistant). A Smoking Contract is then executed indicating the resident's understanding of smoking rules and his/her agree compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision to a resident with severely impaired cognition and a history of falls, failed to implement fall interventions, and failed to document a thorough investigation of a fall for one of three residents (R1) reviewed for falls in the sample of three. These failures resulted in R1 falling, hitting his head, and sustaining a Subarachnoid hemorrhage (brain bleed) on 5/3/23. Findings include: The facility's Resident Accident/Incident policy dated 8/27/21, states Those individuals identified at risk for falls, will be identified for staff to monitor more closely. On a daily basis incidents/accidents will be investigated and reviewed by the facility administrative staff. Necessary intervention changes will be made in the resident's care plan. The facility's Fall Policy and Procedure dated 1/2/19 states, The nurse will complete the necessary documentation: A. Enter a complete description of the incident including, who was notified, any orders received, vital signs, description of any injury, any treatment administered, witnesses, and/or transportation to (Emergency Room) information. R1's electronic medical record documents R1 was admitted to the facility on [DATE] with diagnoses which included, Cerebral Infarction with right sided hemiparesis, Alcohol induced Dementia, and Anxiety Disorder. R1's Minimum Data Set assessment dated [DATE], documents R1 had severely impaired cognition and was unable to ambulate independently. R1's electronic Physician Orders dated 5/2023, document R1 was taking Eliquis (blood thinner) 5 mg (milligram) daily. R1's Fall Evaluations dated 2/3/23, 2/17/23, and 5/16/23, document R1 was at risk for falls. R1's Care Plan dated 2/14/23, states (R1) is at risk for falls due to weakness, poor balance, and confusion. (R1) has had falls prior to his admission. R1's Fall Investigation dated 2/24/23 at 2:05 p.m., documents R1 had an unwitnessed fall in his room trying to get out of bed without assistance. R1 did not sustain any injuries. This same Investigation documents Recommended steps to prevent recurrence: Make sure (R1) is not in the (wheelchair) in his room unsupervised and remove wheelchair from room when he is in bed. R1's Fall Investigation dated 4/25/23 at 4:23 p.m., documents R1 was observed standing up from his wheelchair and slid down to the floor. R1 did not sustain any injuries. This same Investigation states Recommended steps to prevent recurrence: Monitor (R1) and remind to not get up when seen trying to get up. R1's Fall Investigation dated 5/3/23 at 10:50 p.m., documents R1 had an unwitnessed fall in his room. R1 hit his head on the floor causing a quarter sized laceration to right eye area and a bruise to his left lower back area. R1 was sent to the local hospital and was admitted with a diagnosis of Subarachnoid Hemorrhage. R1's Hospital CT (Computed Tomography) of the head or brain report dated 5/4/23, documents R1 sustained a post traumatic acute Subarachnoid Hemorrhage in the left frontal lobe. On 6/8/23 at 10:21 a.m., V10 (Registered Nurse) stated I took care of (R1) on 5/3/23 and one of the (Certified Nurse Aides) had put (R1) to bed not too long before I found him on the floor. He was on the floor closer to the bathroom. I can't remember exactly where his wheelchair was, but it was in his room. I can't say whether he had tried to get in the wheelchair at any point since he is confused and could not tell me what happened. I think he was trying to use the restroom alone due to his diagnosis of Dementia. He can't ambulate alone very far, if at all, without falling. He has a habit of trying to continually get up without assistance. We (the facility) don't use fall alarms anymore, so I know he didn't have one. I had a Certified Nurse Aide in the room with me, but I cannot remember who it was. I should have had her document a statement of what she observed after the fall. On 6/9/23 at 3:00 p.m., V2 (Director of Nursing) stated R1's fall interventions did include to not leave his wheelchair in his room. V2 stated after his first fall that intervention was implemented hoping he would not visualize the wheelchair and try to get out of bed alone. V2 stated R1 had a habit of trying to stand/get up without assistance. V2 stated R1's wheelchair should not have been in his room on 5/3/23 once he was put to bed. V2 stated V10 should have had the Certified Nurse Aide that assisted her write a statement, so we know who else was involved after the fall. V2 stated he was unable to determine who the Certified Nurse Aide was that assisted V10 after R1 was found on the floor on 5/3/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act on and obtain a physician response to a Pharmacist's Drug Regimen Review which documented a clinically significant medication issue for one of four residents (R1) reviewed for physician orders in the sample of four. This failure resulted in R1 incorrectly receiving extra doses of an anti-diabetic medication. R1 was found unresponsive, hypoglycemic and required transfer to the hospital via ambulance. Findings include: The facility's Medication Regimen Review Policy, undated, states, The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The Medication Regimen Review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MRR also involves a thorough review of the resident records and may include collaboration with other members of the interdisciplinary team, collaboration with the resident, family members or other resident representatives. The MRR also involves reporting of findings with recommendations for improvement. All findings and recommendations are reported to the Director of Nursing and the Attending Physician, the Medical Director and Administrator. Procedure: 2. The consultant pharmacist reviews the medication regimen of each resident at least monthly. a. A more frequent review may be deemed necessary i.e., if the medication regimen is thought to contribute to an acute change in status or adverse consequence, or the resident is not expected to stay 30 days. b. Upon admission or re-admission to the facility, the consultant pharmacist performs a MRR in accordance with CMS (Centers for Medicare and Medicaid Services)-N2001. The consultant pharmacist will provide a notice of the MRR having been performed with a Code 0 (no discrepancy) or Code 1 (discrepancy noted), along with a clinical recommendation for each discrepancy noted on admission or re-admission. 6. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the director of nursing, medical director, and prescriber as appropriate. 7. Recommendations are acted upon and documented by the facility staff and/or the prescriber. R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. R1's Census Report documents R1 admitted to the facility on [DATE] and was discharged to the hospital on 5/8/23. R1's After Visit Summary (AVS), dated 5/5/23, documents Discharge Medications with an order for Glipizide 2.5 mg/milligram tab (tablet)-sr/sustained release-24 hr/hour. Commonly known as Glucotrol XL (Extended Release). Take two tablets by mouth daily. R1's Order Summary Report, 5/5/23-5/8/23, documents an order for Glipizide ER (Extended Release) Oral Tablet Extended Release 24 hour 2.5 mg/milligrams. Give two tablets by mouth two times a day related to Type 2 Diabetes Mellitus without complications with a start date of 5/6/23. R1's Drug Regimen Review/DRR from the facility's Pharmacy Company states, Attention Required: Discrepancies Noted. CMS (Centers for Medicare and Medicaid Services) N2001: Drug Regimen Review This form states, In compliance with CMS-N2001: Drug Regimen Review, upon admission/readmission, the resident's medication regimen was reviewed for clinically significant medication issues. After clinical review, the following was noted: Hospital paperwork showed patient (R1) is using Glipizide 2.5 mg 2 (two) tabs (tablets) daily. Order needs to be reviewed and updated per (name of electronic charting system) says 2 (two) tabs (tablets) BID (twice a day). This DRR documents R1's admission date to the facility as 5/5/23 and documents V11 as R1's Physician. The physician/prescriber response section is blank. This form states, In accordance with CMS-N2001, prescriber response must be received by midnight the next calendar day. R1's CMS-N2001 Drug Regimen Review, dated 5/6/23 by V13 (Pharmacist) states, In compliance with CMS-N2001: Drug Regimen Review, upon admission/readmission the resident's medication regimen was reviewed to assess whether any clinically signification medication issues were present. After review it was noted that: Code One, Yes. One or more clinically significant medication issues were identified during the DRR This DRR is electronically signed and dated by V13 (Pharmacist) on 5/6/23 at 11:49 AM. DRR Conversation Records documents the DRR communication was faxed to the facility's nursing station, emailed to V2 (Director of Nursing) and emailed to V12 (Care Plan Coordinator) on 5/6/23 at 11:58 AM and was re-faxed to the facility's nursing station on 5/8/23 at 1:30 PM. On 5/9/23 at 1:27 PM, V13 documents R1 is back at the hospital. R1's Medication Administration Record (MAR) dated 5/1/23-5/31/23 documents an order for Glipizide ER (Extended Release) Oral Tablet Extended Release 24 hour 2.5 mg/milligrams. Give two tablets by mouth two times a day related to Type 2 Diabetes Mellitus without complications. This same MAR documents two Glipizide ER 2.5 mg tablets were given two times a day on 5/6/23 and 5/7/23 at 9:00 am and 5:00 PM. Another dose of two Glipizide ER 2.5 mg tablets is documented as being given again on 5/8/23 at 9:00 AM, 16 hours after the previous dose. R1's Skilled Nursing Facility to Hospital Transfer Form, signed by V4 documents on 5/8/23, R1 was transferred to the local area hospital with lethargy and low blood sugar. On 5/25/23 at 11:27 AM, V10 (Pharmacist) stated that after a review of R1's admission medications were completed a discrepancy noted R1's Glipizide order was entered as 2.5 mg ER two tabs two times a day and the hospital order was ordered for only once a day. V10 stated requests for a clarification were sent to V2 and V12 via electronic mail and a request was sent to the facility nursing station fax number as well on 5/6/23. V10 stated a fax was sent to the nursing station fax number again on 5/8/23. V10 stated no response was received from the facility regarding the discrepancy. V10 stated R1's extra doses of Glipizide could have caused R1's hypoglycemia. On 5/25/23 at 3:51 PM, V2 (Director of Nursing) stated, The minute the nurses got the fax (R1's Drug Regimen Review), it should have been addressed. The faxes are not supposed to sit. We are still investigating this to see what happened. V2 stated since it was a weekend, V2 did not see the electronic mail correspondence from the pharmacy. On 5/25/23 at 3:29 PM, V11 (R1's Physician) stated V11 does not recall receiving notification regarding pharmacy's request for clarification regarding R1's Glipizide medication order. V11 stated that V2 (Director of Nursing) made V11 aware today (5/25/23) that the Glipizide order was ordered incorrectly and that R1 had received more than the ordered dose. V11 stated R1's hypoglycemia on 5/8/23 could have been from the extra doses of Glipizide that was given. On 5/26/23 at 12:10 PM, V9 (Assistant Director of Nursing) stated R1's Drug Regimen Review fax that indicated there were issues with R1's medication orders should have immediately been addressed by the nurses when it was pulled from the fax. V9 stated, Addressing this right away could have prevented a medication error from occurring. V9 stated all nurses are going to be re-educated on the fax machine and the importance of responding to received faxes at huddle at shift change today. As of 5/26/23, R1's medical record did not document a physician response to V13's Drug Regimen Review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe physician orders resulting in a significant medication error of an anti-diabetic medication and failed to order and administer an emergency glucose replacement when a resident's blood glucose levels were critically low for one of four residents (R1) reviewed for physician orders in the sample of four. These failures resulted in R1 incorrectly receiving extra doses of an anti-diabetic medication. R1 was found lethargic, unresponsive and with critically low blood glucose levels. R1 was transferred to the local area hospital via ambulance. Findings include: The facility's Medication Pass Guidelines, dated 3/00, states, Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Physician's Orders-Medications are administered in accordance with written orders of the attending physician. The nurse who receives the order is responsible for transcribing to the chart. The facility's Ordering and Receiving Medications Policy, dated 3/00, states, Purpose: To ensure that medications are available for administration at the correct time, in the correct form and quantity. Procedure: New Orders 1. All new orders must be written on a physician's order sheet. 2. Transcribe written physician orders appropriately to the Medication Administration Record (MAR) and treatment sheets. V11's (R1's Physician) Standing Orders and Guidelines for Patient Care and Reasonable Expected Reviewer's Criteria, signed and dated by V11 on 1/21/16, states, VI. Emergency e. If a known diabetic patient becomes lethargic or shows signs and symptoms of Insulin reaction or hypoglycemia, BGM (Blood Glucose Monitor) the patient. If below 60 and symptomatic, give 1 (one) cc (cubic centimeter/one milliliter) Glucagon and send notification. If unable to BGM patient and symptomatic, give 1 cc Glucagon and send to Emergency Room. The facility's First-Dose and Emergency Medication Kit Policy, undated, states, Policy: Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from (name of the facility's Pharmacy). The facility's (Name of Automated Dispensing System) Item List documents Glucagon 1 mg (One Milligram) Kit is contained inside. The facility's Registered Nurse/Licensed Practical Nurse Job Description, undated, states, Position Purpose: Provide Nursing Care to residents in accordance with clinically accepted practice, governmental regulations, accreditation standards, and consumer wishes and needs. Responsibilities: Requires the ability to apply general nursing techniques and practices, Requires the ability to maintain accurate records, charts and report observations, Requires the ability to follow and give oral and written directions in exact detail and to administer therapeutic prescriptions. Provides routine nursing care in accordance with the physician's orders in conformance with recognized nursing techniques and procedures established standards, and the administrative policy of the facility to which assigned. Maintains clinical charts; reports on the conditions of residents; accepts appropriate telephone communications with the physicians. Assists residents with nursing care problems. R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. R1's Census Report documents R1 admitted to the facility on [DATE] and was discharged to the hospital on 5/8/23. R1's After Visit Summary (AVS) documents R1 was being discharged to the facility after an inpatient hospital stay from 4/15/23-5/5/23. This AVS documents the following: Discharge Medications with an order for Glipizide 2.5 mg/milligram tab (tablet)-sr/sustained release-24 hr/hour. Commonly known as Glucotrol XL (Extended Release). Take two tablets by mouth daily. and Recommendations for your Diabetes: Follow directions for your medicine, meals and exercise, Check your blood sugars often, Stay within your safe blood sugar levels; Treat a low blood sugar right away, and Tell all doctors about your diabetes. R1's Order Summary Report, 5/5/23-5/8/23, documents an order for Glipizide ER (Extended Release) Oral Tablet Extended Release 24 hour 2.5 mg/milligrams. Give two tablets by mouth two times a day related to Type 2 Diabetes Mellitus without complications with a start date of 5/6/23. R1's Drug Regimen Review/DRR from the facility's Pharmacy Company dated and timed 5/6/23 at 11:49 AM by V13 (Pharmacist) documents the following: Code One, Yes. One or more clinically significant medication issues were identified during the DRR; R1's admission date to the facility as 5/5/23; and V11 as R1's Physician. The DRR states, Attention Required: Discrepancies Noted. CMS (Centers for Medicare and Medicaid Services) N2001: Drug Regimen Review This form states, In compliance with CMS N2001: Drug Regimen Review, upon admission/readmission, the resident's medication regimen was reviewed for clinically significant medication issues. After clinical review, the following was noted: Hospital paperwork showed patient (R1) is using Glipizide 2.5 mg 2 (two) tabs (tablets) daily. Order needs to be reviewed and updated per (name of electronic charting system) says 2 (two) tabs (tablets) BID (twice a day). R1's Medication Administration Record (MAR) dated 5/1/23-5/31/23 documents an order for Glipizide ER (Extended Release) Oral Tablet Extended Release 24-hour 2.5 mg/milligrams. Give two tablets by mouth two times a day related to Type 2 Diabetes Mellitus without complications. This same MAR documents two Glipizide ER 2.5 mg tablets were given two times a day on 5/6/23 and 5/7/23 at 9:00 am and 5:00 PM. Another dose of two Glipizide ER 2.5 mg tablets is documented as being given again on 5/8/23 at 9:00 AM, 16 hours after the previous dose. The facility's Packing Slip from the Pharmacy, dated 5/5/23, documents Glipizide ER 5 mg tablets were delivered for R1. R1's Nursing Note on 5/8/2023 at 4:35 PM, signed by V4 (Licensed Practical Nurse) states, (R1) presents as lethargic. Upon assessment bs (Blood Sugar) 46, unable to arouse. (R1) sent to (name of local area hospital) for eval (evaluation) and treat (treatment). All appropriate parties notified. R1's Skilled Nursing Facility to Hospital Transfer Form, signed by V4 documents on 5/8/23, R1 was transferred to the local area hospital with lethargy and low blood sugar. R1's (Name of Ambulance Company) Patient Care Report documents on 5/8/23 paramedics were dispatched Emergency to the facility. This report documents the following: Chief Complaint: Diabetic-Hypoglycemia (Primary); Primary Symptom: Altered Mental Status; Primary Impression: Hypoglycemia; and a blood glucose level of 27. This report states, EMS (Emergency Medical Service) Unit arrived on scene to find (R1) unconscious laying in his bed. (V4/Licensed Practical Nurse) relayed that she came to give the patient (R1) his nightly medications and found him to be in his current state. (V4) relayed that (R1) has a history of Diabetes Type 2 and is only on oral medication. (V4) could not relay the last time (R1) was at his normal and stated she does not usually work over here. (R1) is unable to confirm or deny any pertinent negatives due to being altered. (R1) is being transferred to (name of local area hospital) for further medical care and evaluation. (R1) was unresponsive to all stimuli Post treatment, (R1) was noted to respond to verbal stimuli. Assessment: Hypoglycemia. (R1) was assessed, BGL (Blood Glucose Level) obtained and noted to be 27. On 5/25/23 at 10:33 AM, V2 (Director of Nursing) stated, I definitely would have expected Glucagon to be given if a resident's blood sugar is less than 60. There should have been orders for it (Glucagon). On 5/25/23 at 10:45 AM, V9 (Assistant Director of Nursing) stated that on 5/8/23, V4 (Licensed Practical Nurse/LPN) had yelled for help because R1 was unresponsive to sternal rubbing. V9 stated R1's blood sugars were low and that V4 was trying to get into the box to give Glucagon. V9 stated V4 did not give Glucagon to R1. On 5/25/23 at 2:22 PM, V4 (LPN) stated, On 5/8/23, I entered (R1's) room and he was asleep, snoring. I did a sternal rub and there was no response (from R1). It was a sudden change. I immediately thought of his blood sugar. I checked his blood sugars with the glucometer, and it said it was 46. Someone was calling the ambulance and I went to get the Glucagon. Glucagon didn't pull up on (R1's) list of medications because there was not an order for it. If the Glucagon had pulled up right away on R1's profile, I would have been able to give a dose before (the Ambulance Company) arrived instead of looking around for one. They (Ambulance Company) arrived quick. (R1's) blood sugar had dropped down to 27 by the time (Ambulance Company) came. V4 verified V4 did not administer Glucagon to R1 on 5/8/23 prior to R1 being sent to the hospital. On 5/25/23 at 3:29 PM, V11 (R1's Physician) stated, It's normal procedure that R1's discharge medication orders from the hospital are to be followed and implemented at the facility as ordered. V11 stated, With a blood sugar in the 40s, I would have expected Glucagon to be given (to R1) as an emergency medication (on 5/8/23). V11 stated that V2 (Director of Nursing) made V11 aware today (5/25/23) that the Glipizide order was ordered incorrectly and that R1 had received more than the ordered dose. V11 stated R1's hypoglycemia on 5/8/23 could have been from the extra doses of Glipizide that was given. On 5/24/23 at 1:11 PM, V5 (Licensed Practical Nurse) stated that V5 entered R1's medication orders into the electronic charting system based off of the orders R1 came to the facility with when R1 was discharged from the hospital. V5 stated V5 also faxes the hospital discharge orders to the pharmacy so they can be verified. V5 verified R1's medications were not double checked by another nurse after V5 entered them into the computer. On 5/25/23 at 11:27 AM, V10 (Pharmacist) stated that after a review of R1's admission medications were completed a discrepancy noted R1's Glipizide order was entered as 2.5 mg ER two tabs two times a day and the hospital order was ordered for only once a day. V10 stated the reports were sent to the facility requesting clarification with no answer received. V10 stated R1's extra doses of Glipizide could have caused R1's hypoglycemia. On 5/25/23 at 3:51 PM, V2 (Director of Nursing) verified that R1's Glipizide medication order was transcribed incorrectly by V5 (LPN) and that R1 received more of the Glipizide medication than R1 should have. V2 stated, A reasonably prudent nurse would have double checked the orders with another nurse before submitting them. As of 5/26/23, R1's medical record did not document Glucagon was administered to R1 by facility staff.

Based on interview and record review the facility failed to ensure two residents (R7 and R6) of four residents reviewed for abuse were free from physical abuse. This failure caused R6 to sustain facial fractures. Findings Include: The Facility's Abuse Prevention Program dated 2011 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion This facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. The Facility's Abuse Prevention Program dated 2011 defines physical abuse as the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. An Abuse Investigation form dated 3/9/23 documents (R7) was heard screaming (V8/LPN/Assistant Director of Nursing) ran down the hall and saw (R1) strike (R7) across the face. On 3/16/23 V8 (LPN/ADON) stated When I entered the room (R1) had (R7)'s shirt grabbed up in his left hand and he struck her closed fist with his right. An Abuse Investigation form dated 3/12/23 documents a written and signed statement from V18 CNA (Certified Nursing Assistant) I was sitting in the breakroom, and I heard (R7) screaming loud yelling 'stop'. I ran into her room and witnessed (R1) hitting her and yelling shut the f*ck up. A Final Abuse Investigation Report dated 3/6/23 documents that on 3/3/23 at 10:24 PM (R6) wandered into (R5)'s room. (R5) pushed (R6) and closed the door. (R6) had fallen to the ground, got herself up and opened (R5)'s door again and (R5) slammed the door in (R6)'s face causing her to stumble backwards and grab the right side of her face. This Abuse Investigation Report documents On 3/4/23 (R6) had increased bruising to eye and jaw area and was sent to the emergency room for evaluation. emergency room reported a mildly depressed fracture of the right nasal bone and a nondisplaced fracture of the right zygomatic arch. Mildly displaced fractures involve anterior and lateral walls of right maxillary sinus and the lateral wall of the right orbit as well as the right orbital floor. An Abuse Investigation form dated 3/3/23 documents a written and signed statement from V19 (CNA) (R6) entered (R5)'s room and (R5) pushed (R6) by the upper body then she fell, she got herself back up to enter his room again and he slammed the door on her and it her in the face. On 3/16/23 at 2:00PM V15 (Insurance Representative) stated (R5) called our office and wanted to make it clear that whatever happened on 3/3/23 was an accident, that he just wanted (R6) to get out of his room and leave him alone, he did not mean for her to get hurt. V15 stated (R5) told me that he pushed a lady and she fell then he shut his door in her face.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to assess the need for increased psychosocial cares for one resident (R7) with PTSD (Post Traumatic Stress Disorder) after two physical attacks by another resident (R1) of four residents reviewed for abuse. This failure has caused R7 to be fearful of leaving her room or interacting with other residents and has caused emotional distress for R7. Findings Include: R7's Medical Record documents she was admitted on [DATE] with diagnosis of Dementia, Anxiety, history of suicidal behavior, Delirium due to a known physiological condition, Psychosis not due to a substance or known physiological condition. R7's BIMS (Brief Interview for Mental Status) Score was a 5/15 on admission, indicating severe cognitive impairment for R7. R1's Medical Record documents he was admitted on [DATE] with diagnosis of Vascular Dementia with behavioral disturbances after a CVA (Cerebral Vascular Accident) and Depression. R1's BIMS score on 2/9/2023 was 3/15, indicating severe cognitive impairment for R1. An Abuse Investigation Report dated 3/9/23 documents at 12:30 P.M.(V8/RN) heard a scream from down the hallway and ran down the hall to the room (R7's room) and saw (R1) strike (R7) in the face. An Abuse Investigation Report dated 3/12/13 documents at 1:30 P.M. V14 (RN) saw R1 enter R7's room, R7 began screaming Get out! V14 heard R1 state Shut the f*ck up and saw him strike her right cheek with a closed fist and then began fighting with staff when they intervened. On 3/16/23 at 10:30 A.M. R7 stated I am so scared. R7 tearful and crying. Repeatedly stating I don't know why when asked anything regarding R7 striking her. R1 mimed being punched in the face and said, kept doing it, three times. R7 did articulate that R1 had chased me down in my own place (room) twice. R7 stated she did not want to come out of her room just in case he's out there. I go places only with other people. R7's Medical Record does not include documentation of a psychosocial assessment or R7 being offered any counseling or behavioral health services. On 3/21/23 at 9:15 AM V4 (Social Services Director) stated I spoke to (R7) after both incidents of being hit, she was very unclear about what she wanted. V4 confirmed that there has been no counseling or behavioral health services offered to R7 after being hit by R1. I think (V16/Assistant Administrator) has talked to her some about it (incidents on 3/9/23 and 3/12/23). On 3/21/23 at 9:20 A.M. V6 (Assistant Administrator) stated I spoke to (R7) once about her feelings regarding incidents (being hit by R1 two times.) (R7) was confused and couldn't seem to recall details regarding being hit by (R1) either time. V6 confirmed that no increased monitoring, counseling, or behavioral health services have been provided for R7 since the first incident on 3/9/23. On 3/21/23 at 10:00 AM, V17 (Medical Director) stated For anyone with PTSD (Post Traumatic Stress Disorder) being hit could remind them of their original trauma. (R7) would benefit from some sort of behavioral health or group counseling sessions now that she has been retraumatized.

Based on observation, interview and record review the facility failed to treat, monitor, and prevent new and worsening pressure ulcers that required surgical debridement for one (R69) of five residents reviewed for pressure ulcers in a sample of 26. This failure resulted in house acquired pressure ulcers and worsening pressure ulcers, that required surgical debridement for R69. Findings include: Facility Pressure Ulcer and Skin Care Management Policy, effective 3/2000, documents: a resident who enters the facility without pressure ulcers does not develop pressure ulcers; a resident having pressure ulcers receives treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing; a licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions on admission and weekly; the presence of any pressure ulcer, wound or other skin condition is documented weekly on pressure ulcer or skin report forms in the progress notes and care plan; implements treatment procedures in accordance with professional standards of practice; nursing staff reviews the pressure ulcer prevention and treatment procedures with resident physician; a licensed nurse completes a pressure ulcer or skin report when a pressure ulcer, wound or other skin condition is identified and weekly until healed; and the interdisciplinary team considers and includes interventions for pressure ulcer prevention and treatment to provide an aggressive program of consistent interventions by all staff involved. R69's Nursing Evaluation/Data Collection Form, dated 7/27/22 at 3:30 pm, documents that R69 readmitted to the facility from the local hospital. The Nursing Evaluation Form, skin condition, documents that R69 admitted with a fissure to the coccyx, reddened bilateral heels and a left 5th toe area. The Nursing Evaluation Form does not document measurements or descriptions of the wounds. R69's Treatment Administration Records/TAR, dated 7/27/22 through 8/31/22, documents that R69's bilateral heels treatment was not initiated until 7/29/22, two days after admission and documents a treatment of ointment (betadine) daily and leave open to air. R69's coccyx wound treatment was not initiated until 7/29/22, two days after admission, and documents to cleanse with normal saline and gauze, apply a thin layer of ointment (bacitracin) to the wound bed three times a day and as needed and leave open to air every shift for the fissure. R69's TAR does not document a completed treatment to R69's coccyx on 8/6/22 and 8/7/22 (day shift) and 8/8/22 (night shift). The TAR does not document a completed bilateral heel treatment on 8/6/22 and 8/7/22. R69's TAR, dated 9/1/22 through 9/12/22, documents an order that was started on 8/3/22, for an ointment (Santyl/Collagenase) to R69's left heels, and does not document a completed treatment on 8/6/22, 8/7/22 and 8/23/22. The TAR also does not document a completed coccyx treatment for 9/1/22 and 9/5/22, left heel treatment on 9/1/22 or 9/5/22. The TAR also documents a new treatment for a blister to R69's left foot. R69's Nursing Progress Note, dated 8/30/22 at 3:39 pm, documents that R69 has a new area on left ankle, called wound clinic, waiting on call back. R69's Nursing Progress Note, dated 8/30/22 at 4:38 pm, documents that the facility received a call back from the wound clinic and they will evaluate resident when they see him next week. A dry dressing was applied at that time until R69 seen at wound clinic. R69's Nursing Progress Note, dated 9/9/22, documents that R69 has a new area to the left hip (1.5 centimeters/cm by 1.0 cm). R69's Nursing Notes, dated 8/2/22, document that R69 has a new pressure ulcer to the left posterior heel (2.0 centimeter/cm X 2.5 cm) and is unstageable. Facility Wound Report, dated 9/5/22 through 9/11/22, does not document the measurement or description of R69's left heel/left foot, coccyx or left hip wound. The computer generated Report does document, in handwriting, that R69's left hip was house identified as house acquired on 9/9/22 (no measurements), left lateral ankle blister was identified as house acquired on 9/5/22 (4.0 cm x 4.0 cm, unstageable deep tissues) and a blister was identified as house acquired on 9/2/22 to the fifth toe (unidentified left or right foot and no measurements or wound description). R69's Wound Clinic Notes, dated 9/2/22 through 9/15/22, document that R69 has an unstageable pressure ulcer injury of the left heel. The Notes also document a conversation on 9/15/22 at 9:22 am with V4 (Wound Nurse) requesting something else and they do not have orders to the left hip. The Clinic Notes also document that a pressure reducing mattress is recommended. R69's Wound Clinic Notes, dated 9/2/22, documents the size of R69's left heel wound as 2.6 cm x 6.5 cm x 0.2 cm and black eschar (moderate serous drainage) and the left lateral ankle wound size is 3.2 x 2.5 x 0.1 (moderate serous drainage). On 9/15/22, at 1:20 pm, V4 (Wound Nurse) was changing R69's wound dressings. When V4 removed R69's left heel soiled dressing it was undated and not signed by a nurse. R69's entire heel was completely covered with black eschar (approximately 2.5 inches by 2.5 inches, with scant brown drainage). V4 verified that a new scabbed area to R69's right outer heel was identified (approximately 1.0 cm x 1.0 cm) and needed a treatment order. R69's coccyx peri-wound area was reddened and open, measuring approximately 2.0 X 1.0 cm, with no drainage, and did not have a treatment/dressing in place. R69 had an area to the left outer 5th toe, that was black with eschar and no treatment/dressing was in place. R69's right hip was open and did not have a dressing in place. R69 was not on an air mattress. On 9/15/22, at 1:20 pm, V4 (Wound Nurse) stated, I am brand new at the facility. I just saw this new area on (R69's) right outer heel just now. I will have to get a treatment order for that. It is about the size of a dime and is scabbed. (R69's) wounds were getting treated here in the facility, but because they have all gotten worse, now we have to send him to the wound clinic for treatment. He just started going there towards the end of August. His wounds have gotten worse. Every time I contact the wound clinic, for help, they just tell me to wait until his next visit, so I have not always put treatments in place, but recently I have started just calling our Medical Director for advice. I think (R69) was sent to the Wound Clinic to rule our vascular issues, but (R69's) left hip, heel and outer foot are all pressure ulcers. I think that left 5th great toe is not pressure, but the others probably are due to the location. On 9/15/22, at 1:42 pm, V3 (Assistant Director of Nursing/ADON) stated, (R69) admitted back to the facility on 7/27/22, with just reddened bilateral heels that were not open, a fissure on his coccyx and an area on the 5th left toe. (R69's) areas have gotten worse and now he goes to the wound clinic for treatment. We did not have a wound nurse and our wound documentation is not very good and does not document all of (R69's) weekly measurements or wound description information, as we should have been doing. We have a new wound nurse now that just started a week or so ago. On 9/15/22, at 9:22 am, V18 (Wound Clinic/Registered Nurse) stated, (R69's) first visit here was on 8/19/22 and has only been seen three times. Some of R69's wounds did worsen, and some did require surgical debridement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility's Transfer Between Surfaces policy dated 3/00, documents It is better to have another staff member assist with a transfer than to risk injury. Determine the required sequence of the activity and determine when and how the client will require physical assistance. 2. R57's minimum data set (MDS) dated [DATE] documents Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Two plus person physical assist. R57's X-ray results dated 9/9/22 documents Chronic proximal fibula fracture. On 9/13/22 at 9:45 AM, R57 observed sitting in wheelchair with her right leg propped up with an immobilizing brace on it. On 09/13/22 at 9:46 AM, R57 stated I was dropped during a transfer last week. They wound up fracturing my right knee. (V11, Certified Nursing Assistant (CNA)) was transferring me when I fell. It happened last Monday or Tuesday. They had a mobile X-ray come in on Friday to X-ray my knee and come to find out, my knee is fractured. So now I have to wear this knee brace. On 09/14/22 at 1:32 PM, V11, CNA, verified he was transferring R57 last week and had to lower her to the floor. V11, CNA, stated I was transferring her (R57) by myself when she lost her balance and I had to lower her to the floor. I reported it to the nurse. On 9/14/2 at 1:40 PM, V3, Assistant Director of Nursing (ADON) verified R57's MDS documents she is a two person assist with transfer and stated, There should have been two people helping her. On 9/15/22 at 12:35 PM, V12, CNA stated (V11, CNA) reported to me that (R57) fell. I reported it the nurse. (V11, CNA) was the only one in the room when (R57) fell. On 9/15/22 at 3:10 PM, V18, Physician, stated (R57)'s fracture is not from the fall. She had a pre-existing fracture that was exacerbated from the fall. 3. R322's fall report dated 2/8/22 documents CNA to this nurse stating when transferring residents to wheelchair, resident leaned forward and went to knees. Resident did not hit head. Resident to be transferred with two for assist in the future. R322's MDS dated [DATE], documents Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Two plus person physical assist. On 9/14/22 at 1:42 PM V3, ADON, stated (R322) required two staff members for transfers during his fall on 2/8/22. However, only one staff member was transferring him. It's in the fall investigation and we put the intervention in the care plan to insure there's always two people when transferring him. Based on observation, interview and record review the facility failed to investigate and prevent multiple injuries for one resident (R44) of three residents reviewed for wounds from injury in the sample of 26. This failure resulted in an infection of an elbow wound requiring antibiotics and isolation precautions. The facility also failed to use the assessed number of individuals needed to transfer residents for two residents (R57 and R322) of eight residents reviewed for falls in a sample of 26. Findings include: 1) Facility Policy/Resident Accident/Incident Policy dated/revised 8/22/21 documents: It is the policy of (the facility) to provide a safe environment for all residents. Residents that end up with an unexplained bruise or skin tear will be investigated to ensure there has been no abuse. On a daily basis incidents/accidents will be investigated and reviewed by the facility administrative staff. Necessary intervention changes will be made in the resident's care plan. The ADON (Assistant Director of Nursing) will discuss, instruct, supervise and/or inservice the staff or residents' plan of care (interventions) in an effort to improve the safety of our residents. Changes will be made as often as necessary to keep our residents as safe as possible. Current Physician's Order Report indicates R44 was admitted to the facility on [DATE] with diagnoses that include Huntington's Disease. Physician's Order dated 9/5/22 indicates R44 is on Contact Isolation due to MRSA (Methicillin Resistant Staphylococcus Aureus) infection right elbow. Physician's Order indicate antibiotics were initiated on 8/18/22 and completed on 8/29/22 for MRSA right elbow wound. Current Care Plan indicates R44 has risk for skin injury to due abnormal movements and identifies right elbow wounds from 7/12/22 and left elbow wounds from 7/31/22. Care plan indicates interventions identified on 12/11/19 include elbow protectors and (fabric protective arm sleeves) ordered by the MD (Medical Doctor). Intervention dated 12/11/19 also include to pad bed rails, wheelchair arms or any other source of potential injury if needed. On both 9/13/22 and 9/15/22 R44 was sitting in a recliner style-high back wheelchair with legs stretched out fully on the bed. R44's recliner chair was pushed up completely to the side of the bed to allow R44's legs to be supported. R44's door had posted signs indicating R44 was on Contact Precautions. R44 had a gauze wrap wound dressing on both elbows - no elbow or fabric arm/skin protectors. On both days R44 was wearing a short sleeve T-shirt with exposed skin from mid upper arms to fingertips. Both of R44's exposed upper arms were noted to be resting directly on the metal portion of the arm rest on both sides of the chair. The non-metal portion of the arm rest was made of a hard rubberized material. R44's head rested on plastic support straps and not on the cushioned headrest due to R44's position in the chair. R44 had severe frequent uncontrolled jerking movements of bilateral arms, legs and torso. During these movements R44's arms were noted to jerk and flail against various surfaces of the chair including the unpadded arm rests. On 9/15/22 at 10:15 am V4, Wound Nurse stated that R44's chair should have padding to cover the exposed hard surfaces especially over the metal on the armrests. V4 stated Even the non-metal part of the armrest isn't really cushioned. V4 stated that R44 has a new (injury) wound on his left leg that she assumes happened the night before last. V4 stated she did not know what R44 hit his leg on or if an incident report was done. At that time a gauze wrap dressing was noted to R44's left mid shin. V4 stated it would be helpful to know what (R44) actually caused the wound. Nurse Note dated 9/15/22 at 6:55 am indicates R44 has a new area to left lower leg measuring 2 cm (centimeter) x 1.4 cm. Wound Physician Notes dated 9/13/22 indicates R44 has five different wound sites: Site #2: right upper elbow partial thickness wound; etiology infection Site #3: non-pressure wound of left elbow; etiology trauma/injury Site #4: non-pressure wound of right anterior elbow due to traumatic injury; etiology trauma/injury Site #5: Stage 3 pressure wound right hip Site #6: non-pressure wound of right lower elbow due to trauma/injury Each of the elbow wound sites list the wound physician's recommendations as Off-load wound, reposition per facility protocol and Elbow protector. Current facility wound log indicates R44's right upper elbow wound type as friction.' On 9/15/22 at 11:45 am V3, ADON (Assistant Director of Nursing) and V4, Wound Nurse stated that R44's Site #2 etiology is friction and friction would be classified as trauma/injury. On 9/16/22 at 1:18 pm ADON acknowledged that R44's chair should be padded better, and no incident/accident reports were done for the injuries R44 sustained. On 9/16/22 at 2:00 pm V1, Administrator stated, (R44's) whole environment needs to be reviewed for safety.