**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop an effective plan to prevent and/or reduce the risk of falling for a resident identified to at high risk for falls, and failed to follow their fall prevention protocol to complete fall risk assessments quarterly and accurately assess and document fall risk factors. This affected 6 of 6 residents (R1, R2, R4, R5, R6 and R7) reviewed for falls and fall risk assessments. This failure resulted in R1 having multiple falls R1 had a fall in his room on 8/27/24 at 7:45AM, and then another fall same day at 1:47PM in the dining room that resulted laceration in left side eye brow forehead requiring sutures on 8/27/24 and third fall on 9/12/24 in the dining room that resulted in left eyebrow laceration re-opening. Findings Include: R1 is [AGE] year old resident and still currently in the facility. BIMs score of 2 (severe cognitive impairment). Fall risk assessment dated [DATE] scored 13, and on 9/13/24 scored 14. On 10/24/24 at 9:30AM, V12 (Restorative Nurse/Fall Coordinator) stated that a resident is consider high risk for fall if they scored 10 or higher on the fall risk assessment. V12 stated that residents with a history of falls and impulsive behaviors would have someone close to resident to monitor for any behavior. R1 has a careplan for actual fall with major injury related to: nasal bone fractures, Parkinson's disease, left hip replacement, bipolar disease, developmental delay, ESBL (extended spectrum beta-lactamase -- bacteria) in the urine and acute kidney failure, poor balance, poor communication/comprehension, unsteady gait, impulsive behavior dated 9/19/24. Behavior Note documented on 8/27/24 at 7:45AM, reads in part: R1 was observed sitting on the safety mat next to the bed, with the bed in lowest position. On 10/23/24 at 2PM, V3 (LPN) stated that the incident was unwitnessed, V3 saw R1 lying on the floor mat next to his bed, bed was in low position. I do not know how R1 got himself to the floor mat. R1 was not able to explain how it happened. I asked V2 DON (director of nursing) if I should document it as a fall, but V2 said to document it as a behavior because no one saw him fall off the bed. On 10/24/24 at 9:30AM, V12 (Restorative Nurse/Fall Coordinator) stated that a fall incident is a change of plane. If fall unwitnessed and if the resident is not able to explain what happened, it is considered a fall incident. V12 stated that the fall incident should be documented and a fall risk assessment should be completed. On 10/24/24 at 11AM, V2 (DON) stated that the incident happened early morning and that it was not a fall, because it was not a change of plane. V2 stated that R1's floor mat is the same height as his bed. R1 rolls off the bed, and the floor mat is the same height as his bed. Bed in low position. Floor mat is in place when R1 is in bed and when R1 is out of bed, we take the mat up and put it against the wall of R1's room, it does not leave R1's room. On 10/24/24 at 11:15AM, the distance from the floor to the top of R1's mattress/bed was observed to be about 15 inches. The height of the floor mat was observed to about one inch. R1 was not observed to be present in R1's room. R1's floor mat was positioned on floor next to R1's bed. On 10/24/24 at 11:16AM, V4 CNA (certified nurse aide) stated that R1's bed and floor mat is what R1 has always had since admission to this facility. V4 acknowledged that R1's top of floor mat is not at the same height as the top of his bed. On 10/24/24 at 2:10PM, V4 CNA stated that R1 is usually awake when she arrives at 6:00AM. V4 stated that R1 should be on the get up early list. stated that R1 will activate his call light when he wakes up in the morning for toileting assistance. R1 needs prompt staff response to his call light. V4 stated that she did not see R1 sit himself on the floor on 8/27/24, when she arrived he was on the floor. Facility reported incident with date of occurrence of 8/27/24, reads in part: Thorough investigation completed. Medical record review and interviews of witnesses reveals on 8/27/24, R1 sustained a witnessed fall. Prior to the fall, R1 was notes sitting in the dining room. R1 did not request for assistance, but quickly got up to grab a cup of water, then stumbled on the table resulting in a fall. R1 sustained an opened area on the left eyebrow. Medical records review indicates that prior to admission, R1 has a history of acute comminuted mildly depressed bilateral nasal bones fractures with slight rightward deviation of the nose, acute nasal bone fracture which is superimposed upon an old chronic nasal bone fracture. R1 was transferred to the hospital for further evaluation and was diagnosed with closed fracture of nasal bone age indeterminate and laceration of the left eyebrow with 7 stiches. On 10/23/24 at 11:15AM, V3 (LPN) stated that on 8/27/24, around after lunch, staff alerted V3. V3 come here we need you. Few steps away from walking in the hallway. I just passed by the dining room V3 stated that V3 saw R1 on the floor. R1 lying on the side, with active bleeding under eye and wheelchair right next to R1. Wound care came after me and attended to the wound. R1 is extensive assist and able to self-propel, propels with his feet Does not use footrest. R1 needs assistance with standing due to cognition and poor safety awareness with impulsive behavior. R1 is high risk for fall. Staff are already on alert for fall, staff keep extra eye on R1 to prevent from falling. On 10/23/24 at 11:40AM, V4 (CNA), stated that on 8/27/24, V4 just changed R1's clothes after lunch meal, pushed R1 into the dining room. V4 stated that V4 heard an emergency bathroom call light alarming and she did not put any resident in the bathroom so V4 left the dining room to attend to call light. V4 stated I am not sure if any other staff member was in there. Waiting for activity staff to come around. When I returned they are picking R1 up already from the floor. R1's gait is very unsteady. R1 has a behavior of trying to get up and reaching for whatever is in front of him. R1 is a reacher. R1 is going to get whatever is in front of him, especially food and drink. R1 is a busy resident, would try to get everything and would reach anything in front of him. On 10/23/24 at 1:35PM, V10 (Restorative Aide) stated that R1 was sitting in the chair and R1 reached for some water. R1 was in the long table in the dining room. R1 stood up and fell forward. R1 hit the ground. V10 stated V10 was sitting in the alternate side of the table. There were 5 or 6 residents in the dining room. V10 stated that this was the first time watching R1 in the dining room, V10 was not aware of any impulsive behavior of R1. V10 stated V10 got up but was not able to stop the fall. We try to prevent falls. I do not know if he is high risk for fall. R1's hospital record dated 8/27/24, reads in part: 2.5 cm laceration located to the left forehead eyebrow. 2 deep sutures to close soft tissue and 6 superficial sutures to close the skin. CT (computerized tomography) scan of R1's head/brain with an impression of mild left forehead soft tissue swelling and age indeterminate mildly depressed nasal bone fracture. IDT FALL COMMITTEE NOTE dated 8/30/24, reads in part: Contributing factors: impaired memory, confused, anti-hypertensive user, antipsychotic use, gait imbalance, incontinent, weakness and narcotic use. Prior interventions and support provided: bed in lowest position, behavior monitoring, non-skid socks/footwear in place, call light in reach, and R1 was brought close to the dining room/nurses station. Root cause of the fall determined by IDT: R1 was impulsive behavior attempted to grab a cup of water from the table in the dining room and stumble on the table. R1 requires 1 person assist with ADL and transfer. New intervention put at the time of the fall, bed moved against the wall to prevent from sliding out. Anti-slip mat and anti-rollback were added to R1's wheelchair. Floor mat added to the side of R1's bed. Fall initial occurrence note dated 9/12/24, reads in part: R1 had an un-witnessed fall 09/12/2024 4:45 PM Location of Fall: Unit 1 Dining room, Nurse was told by RCS (Resident Aide) that R1 fell, when the writer went to Unit 1 dining room, RCS already put R1 back on his wheelchair. Noted small blood on the floor and left upper eyebrow. Sent to local hospital for evaluation. Nurses Note dated 9/12/2024 at 21:42, reads in part: Back from local hospital and after being evaluated with diagnosis .of fall initial encounter, Injury of Head, initial encounter, Acute Cystitis without hematuria. Sutures from left eyebrow off, steri- strips intact and covered with band aid. No discoloration noted at this time. On 10/23/24 at 3pm, V11 (RN) stated that a resident aide informed V11 about R1 fall. Dining room R1 blood on the floor, and noted R1 already on the wheelchair. Blood on the left eye brow. Sutures still present on the laceration, and noted blood coming out from that area, small amount. Dry dressing and bleeding stop. Sent out for further evaluation. R1 returned and hospital removed sutures and placed steri strips. R1 usually bend forward and reach for something, and that probably what happened. Last seen resident in the dining room and the aide was there, female RCS. On 10/24/24 at 11AM, V2 (DON) stated that the fall incident on 8/27/24, witnesses interviewed, they bring R1 in the dining room. Restorative was there, she was sitting around the corner not close to R1, She was not able to catch the fall. R1 was trying to grab a cup of water. Reached and fell forward from sitting in the wheelchair. R1 has history of multiple falls when he was at the group home. R1 has multiple falls prior to coming in the facility. High risk for fall that's the reason we bring him in the dining room, R1 is very impulsive, no sense of safety awareness. Supervision in the dining room. Stated that the fall incident on 9/12/24, R1 was in dining room and they are people supervising. CNA was in the dining room. CNA observed R1 dropped the spoon on the floor and R1 bent down and fell of the wheelchair. R1 is quick, and people were watching R1. Facility does not do one on one supervising. There are other people also in the dining room that they have to watch. Staff are monitoring other high risk for fall residents and the facility do not do one on one. IDT FALL COMMITTEE MEETING NOTE dated 9/13/24, reads in part: Contributing factors: Impaired memory. Situational factor: behavior symptoms. Root Cause: impulsive behavior attempted to pick spoon from the floor in the dining room when he slid and fell. On 10/23/24 at 1:35PM, V10 (Restorative Aide) stated that if any residents with such behavior and history of fall. Staff keep eyes on them and monitoring. Staff should be sitting close enough to be able to redirect the resident. Close enough to stop the reaching behavior of R1 for safety and prevent fall incident. Fall Prevention Program with a revision date of 11/21/2017, reads in part: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The fall Prevention Program includes the following components: Methods to identify risk factor, methods to identify residents at risk, use and implementation of professional standards of practice, immediate change in interventions that were successful, communication with direct care staff members. Care plan incorporated: identification of all risk/issue, address each fall, interventions are changed with each fall as appropriate, preventative measure. Safety interventions will be implemented for each resident identified at risk. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. R2's medical record notes R2 was admitted with diagnoses including, but not limited to, high blood pressure, hypertensive urgency (occurs when blood pressure readings are 180/110 or higher but there is no organ damage or symptoms), history of falls, and primary osteoarthritis of ankle and foot. R2's POS (physician order sheet) notes an order, dated 5/14/24, for amlodipine besylate (medication to treat high blood pressure) 10mg (milligrams) oral daily. On 5/15/24, there is an order for hydralazine (medication to treat high blood pressure) 50mg oral every 8 hours. On 6/25/24, there is an order for olanzapine 2.5mg oral for mood/agitation. On 8/13, there are orders for furosemide (medication to treat fluid retention) 20mg oral daily. On 8/22/24, there is an order for lisinopril (medication to treat high blood pressure) 10mg oral daily. R2's admission fall risk assessment, dated 5/14/24, notes R2 does not take any high risk medications. R2 was receiving amlodipine besylate. It also notes R2 does not have any predisposing diseases, such as arthritis. R2 was admitted with a diagnosis of primary osteoarthritis of ankle and foot. It notes R2 is not at risk for falls. R2's fall risk assessment, dated 7/10/24 at 5:45PM, notes no falls in the past three months. This assessment was completed after R2 fell at 5:00PM. It notes R2 is not at risk for falls. R2's fall risk assessment, dated 9/11/24, notes R2 takes 1-2 high risk medications currently or within last 7 days. R2 was receiving amlodipine besylate, hydralazine, and olanzapine. It also notes no falls within the past three months. R2 fell on 7/10/24. It also notes no predisposing diseases, such as arthritis. R2 was admitted with a diagnosis of primary osteoarthritis of ankle and foot. R2's gait/balance was not assessed. R2 was hospitalized 9/3-9/11 with medication changes. This was not identified on R2's assessment. It notes R2 is not at risk for falls. R4's medical record notes R4 with diagnoses including, but not limited to, stroke with paralysis affecting left dominant side (primary diagnosis on 8/3/2023) and history of falling. R4's fall risk assessment, dated 8/7/24, notes no falls within the past three months. This assessment was completed post fall. It also noted R4 does not have any predisposing diseases, such as stroke. It notes R4 is not at risk for falls. R4's fall risk assessment, dated 8/21/24, notes R4's gait/balance was not assessed. It also notes R4 does not have any predisposing diseases, such as stroke. It notes R4 is not at risk for falls. R4's fall risk assessment completed prior to 8/7/24 was done on 10/18/23. On 10/24/24 at 9:40AM, V12 (restorative nurse/falls coordinator) stated that V12 has been the falls coordinator at this facility for the past two years. V12 stated that a fall risk assessment is completed on all residents on admission, re-admission, status post fall, and quarterly. V12 stated that a resident is identified as a high risk for fall if the fall risk assessment score is 10 or higher. V12 stated that the resident's care plan would note resident is at risk for falls not at high risk for falls. V12 stated that nurses are expected to complete the fall risk assessments. V12 stated that the IDT (interdisciplinary team) will assess each resident and determine if the resident is at risk for falls. When questioned where is the IDT's assessment documented in the resident's electronic medical record, V12 did not respond. V12 stated that R2 had an unsteady gait and was on this facility's falling list. When questioned reason why R2 would be on the facility's falling list if all of R2 fall risk assessments, dated 5/14, 7/10, and 9/11, note R2 is not at risk for falls, V12 responded that the fall risk assessment is done at the discretion of the nurse. When questioned if V12 reviews the resident's fall risk assessment for accuracy, V12 responded 'no'. R4's fall risk assessments were reviewed with V12; R4 is identified as not at risk for falls. When questioned why R4 does not have any fall risk assessments done from 10/8/2023 until R4 fell on 8/7/2024, V12 responded she does not know. V12 stated that R4 is unable to stand. When questioned if the nurse is expected to check all that apply for the R4's gait/balance, V12 did not respond. When questioned if R4's fall risk assessments were accurate, V12 responded she does not know. R5's medical record notes R5 with admitting diagnoses including, but not limited to, multiple fractures - skull, ribs, cervical spine, history of falling, and high blood pressure. R5's only fall risk assessment was completed on admission on [DATE]. R6's medical record notes R6 with diagnoses including, but not limited to, high blood pressure, difficulty in walking, abnormal posture, and lack of coordination. R6's fall risk assessment, dated 10/8/24, notes no falls within the past three months. This assessment was completed post fall. It also notes R6 is not at risk for falls. R7's medical record notes R7 with diagnoses including, but not limited to, stroke with paralysis affecting right dominant side (primary diagnosis on 12/16/2021), seizure disorder, high blood pressure, Parkinson's disease, and history of falling. R7's only fall risk assessment since admission on [DATE] was completed on 2/24/2022. This assessment notes R7 does not have any predisposing diseases, such as high blood pressure, stoke, seizures, or Parkinson's disease. A review of the facilities fall prevention program, revised 11/21/2027, notes a fall risk assessment will be performed by a licensed nurse at the time of admission. A fall risk assessment will be performed at least quarterly and after any fall.

Based on observation, interview and record review the facility failed to perform pressure ulcer dressing changes as ordered by the physician for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 9. This failure resulted in R1 developing an infected right heel pressure wound. The findings include: 1. R1's Wound Assessment Report dated 2/4/24 shows that she admitted to the facility with an unstageable pressure ulcer on her right heel measuring 5.5 cm (centimeters) x 6.8 cm x 0.1 cm with light serosanguineous (pink thin fluid secreted from wounds in the healing process) drainage present. R1's Wound Physician note dated 4/17/24 shows that R1's right heel pressure ulcer was now a stage 4 pressure ulcer measuring 8.5 cm x 5 cm x 1.9 cm. R1's right heel pressure ulcer had heavy purulent (thick pus like drainage from an infection) drainage and the wound progress was not at goal. That same report shows that Metronidazole (antibiotic) 250 mg crushed and sprinkled on wound daily for odor was ordered on 4/3/24 for 30 days. R1's Right Heel Wound Culture Report collected 4/19/24 shows moderate growth of escherichia coli, proteus mirabilis and enterococcus faecalis. R1's Treatment Administration Record (TAR) for April shows an order dated 4/3/24-4/14/24 for: Right heel-Dakins 0.125%-cleanse area with NSS (normal saline), pat dry, pack with Dakins wet to moist gauze, cover with ABD pad, and wrap with kerlix twice daily or as needed. Every day and evening shift for wound care. R1's TAR for April and May show an order dated 4/14/24-5/13/24 for: Right heel-Dakins 0.125%-Cleanse area with NSS, pat dry, pack with Dakins wet to moist gauze, cover with ABD pad, and wrap with kerlix twice daily or as needed. Every day and night shift for wound care. R1's April and May TAR shows that these dressings were not performed on 4/5 (Friday (Fri) evening), 4/9 (Tuesday (Tues) evening), 4/13 (Saturday (Sat) evening), 4/14 (Sunday (Sun) day), 4/15 (Monday (Mon) night), 4/17, 4/18, 4/19 (Wed, Thurs, Fri night), 4/20, 4/21 (Sat/Sun day), 4/22, 4/23, 4/24, 4/25 (Mon-Thurs night), 4/27 (Sat day and night), 4/28, 4/29 (Sun/Mon day), 5/2, 5/3 (Thurs/Fri day), 5/5 (Sun day), 5/6 (Mon night), 5/8 (Thurs night), 5/11 (Sat night) and 5/12 (Sun day and night). On 6/28/24 at 2:02 PM, V11 said that he does not know why so many dressing changes were not signed off on R1's April and May TAR. V11 said that anytime a dressing is changed, it should be documented on the TAR. V11 said that R1's Hospice nurse would perform dressing changes when she visited R1. R1's Hospice Communication Log shows that the Hospice Nurse did not see R1 on any of the above days besides 5/3/24. On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all treatments should be documented in the TAR when done. V2 said, If it was not documented, it was not done. On 6/28/24 at 2:28 PM, V12 (R1's Wound Physician) said R1 was receiving treatment for a wound odor and increased drainage of her heel pressure ulcer. V12 said that they did a culture of the wound and it came back showing an infection. V12 said that it is important to do dressing changes as ordered. V12 said that if dressing changes are not done, the wound could become infected. V12 said that if the wound already had an infection and they were not done, that could keep the bacteria in the wound and limit healing. R1's Care Plan show that she was on antibiotic therapy, Bactrim DS related to an infection of her right heel wound initiated on 4/16/24 with intervention to include: Wound treatment applied as ordered. The facility's Pressure Injury and Skin Condition Assessment Policy revised on 1/17/18 shows, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration . 2. R2's Wound Assessment Report dated 3/28/24 shows that she admitted to the facility with an unstageable left trochanter pressure ulcer measuring 6 cm x 5.5 cm x 0.1 cm. On 6/28/24 at 10:35 AM, V11 performed a dressing change to R1's right hip pressure wound. V11 removed the dressing and there was a small open area on her right hip present. R1's May TAR shows an order dated 5/3/24-5/28/24 for: Left hip-collagen with silver/acetic acid 0.25%-cleanse area with acetic acid, pat dry, apply silver collagen sheet and cover with dry dressing every two days or as needed. Every day shift every 2 days for wound care. R2 did not receive a dressing change for 8 out of the 13 ordered dressing changes. R2's May TAR shows an order dated 5/30/24-6/13/24 for: Left hip- Collagen with silver-Cleanse area with acetic acid, pat dry, apply silver collagen and cover with dry dressing daily or as needed. R2 did not receive a dressing change for 7 out of the 13 ordered dressing changes. R2's June MAR shows an order starting 6/14/24 for: Left hip-Collagen-Cleanse area with acetic acid, pat dry, apply collagen sheet and cover with dry dressing daily or as needed. Every day shift for wound care. R2 did not receive 9 out of 15 ordered dressing changes. On 6/28/24 at 2:02 PM, V11 said that he does not know why so many dressing changes were not signed off on R2's May and June TAR. V11 said that anytime a dressing is changed, it should be documented on the TAR. On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all treatments should be documented in the TAR when done. V2 said, If it was not documented, it was not done. The facility's Pressure Injury and Skin Condition Assessment Policy revised on 1/17/18 shows, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect a confused and vulnerable resident (R1) from being physically abused by a staff member and failed to follow their abuse policy by not preventing staff to resident physical abuse. This failure resulted in R1 obtaining facial injuries with noted scratches with active bleeding, swelling, pain and bruising that required the resident to be transferred emergently to a local hospital for further evaluation. Findings include: R1's face sheet indicated that resident admitted to the facility from an acute care hospital on [DATE] and has a past medical history not limited to: Alzheimer's Disease, Seizures, Vascular Dementia, Psychosis, Difficulty in Walking, Lack of Coordination, Weakness, Abnormalities of Gait and Mobility, Malignant Neoplasm of Brain, Atrial Flutter, Cerebral Infarction, and History of Falling. R1's Minimum Data Set Section C dated 11/13/2023 documented a score of BIMS (brief interview for mental status score) of 11 which indicates some cognitive impairment. R1's care plan last reviewed 11/13/2023 reads in part: use antidepressant medication (amitriptyline) related to Depression (11/20/2023); alteration in neurological status related to disease processes of Alzheimer's Disease and Vascular Dementia (11/20/2023); feelings of sadness, emptiness, anxiety, uneasiness, depression characterized by: ineffective coping, low self-esteem, tearfulness, motor agitation, withdrawal from care/activities related to brain deterioration, dependence, relocation, recent admission to long term care, decline in visits from family, decline in health (12/01/2023); given my poor and compromised health status, cognitive issues, physical decline and need for 24-hour care, the Inter-Disciplinary Team (IDT) recognizes that I am considered a vulnerable adult. Comprehensive assessment reveals a history of suspected abuse, neglect, exploitation and/or additional factors that may increase my susceptibility to abuse/neglect related to diagnosis of Dementia (12/01/2023). R1's active physician orders reads in part: Aripiprazole Oral Tablet 5 milligrams (mg) give 1 tablet by mouth one time a day for Anxiety; Amitriptyline HCl Tablet 75mg give 1 tablet by mouth at bedtime for depression; Apixaban Oral Tablet 2.5mg give 1 tablet by mouth two times a day for prevent blood clots. R1's behavior note dated 11/30/2023 04:43 documented verbal and physical aggression with no documentation of a physical altercation or of any noted injuries. R1's nursing progress note dated 11/30/2023 08:50 indicated resident was sent to local hospital for further evaluation and assessment. Reason for evaluation and assessment was not indicated, no documentation of a physical altercation, any noted injuries, or provided first aid was noted. R1's hospital records dated 11/30 2023 indicated resident was seen for contusion/abrasion of face and documented no fractures were found with hematoma (bruise) to left periorbital (eye) and left mandibular (jaw) soft tissues. R1's facility reported incident report dated 11/30/2023 indicated R1 stated that V5 (Certified Nursing Assistant) allegedly touched his face who was suspended pending investigation of physical abuse. Police report #23-02658. Fire department report #23-3147. On 12/01/2023, facility provided V5's statement dated 11/30/2023 that reads in part: while approaching R1's bed to try and calm him down, R1 kicked V5 in the stomach. V5 then said she grabbed R1's feet to help put the back into bed when R1 tried to hit her and had punched her breast. V5 added that she was trying to cover herself with her hands to keep space between her and R1 when another staff member came in between her and R1 and took V5 out of the room. Also provided was V7's (Licensed Practical Nurse) statement dated 11/30/2023 which indicated V7 was providing care to R1's roommate with the privacy curtain pulled when she heard R1 start yelling. V7 said she then went around the curtain and saw R1 kicking V5 (Certified Nursing Assistant) and proceeded to take her out of the room. On 12/01/2023 at 11:09 AM, observed three small scratches that were scabbed to the left side of R1's face, near the end of his corner eyebrow area, small light purple colored bruise below scabbed areas, and red scratch to R1's right cheek that was approximately three inches in length. When asked how the facial injuries occurred, R1 said I got the sh*t kicked out of me by a little girl. R1 continued to state that he didn't recall the date of the incident, but said it happened a few days ago. R1 then said on that night, he was lying in bed when she (V5) came over to me and smacked me on my head with her hand. R1 added that he was struck to the head and face a few times. R1 then showed surveyor purple colored bruising to his left side/rib area and to his left lower back/flank area but said he could not recall how these injuries had occurred. R1 informed surveyor that he has had a few falls while transferring himself since coming to this facility. R1's abuse/neglect screen dated 12/01/2023 12:02 documented a score of 7 which indicated resident is at a high risk for abuse (Time stamp indicates assessment was completed during and not prior to this complaint investigation). No other abuse/neglect screening was found in R1's electronic medical record. On 12/01/2023 at 12:05 PM and 12:13 PM, attempted to call V5 (Certified Nursing Assistant) with no answer at either attempt, message left. On 12/02/2023 at 12:43 PM, attempted to call V5 but was unsuccessful. On 12/01/2023 at 12:54 PM, V1 (Administrator) said R1 reported being smacked by a small lady then said the alleged incident occurred on third shift, so by the process of elimination from R1's description, V5 was identified as the alleged perpetrator and was suspended pending outcome of the facility's investigation. V1 also added that she has been trying to contact V5 but was unable to reach her, then said that she thinks V5 is scared. On 12/01/2023 at 1:56 PM V8 (Certified Nursing Assistant) said incident happened Wednesday night into Thursday morning (11/29-11/30/23) at approximately 2:30 AM. V8 then said that during rounds, V7 (LPN) asked her and V5 (CNA) for assistance with R1's roommate when R1, who was lying in bed, started to yell out is there a party in here. V7 added that V5 had left the room to get more supplies while she went to the other side of room with V7 with the privacy curtain pulled around resident's bed. V8 said she then heard R1 yelling out racial slurs that was coming from the other side of curtain, so she didn't know where V5 was in the room or what she was doing. V8 then said she started hearing a commotion that sounded like an altercation, so she came from behind the curtain and saw R1 sitting on the edge of the bed and V5 was standing in front of him. She added that she saw R1 kicking V5 to her stomach area while V5 was pushing R1's legs away from her with her hands trying to stop R1 from kicking her. V8 added that she saw bleeding to the top of R1's left face, by his eyebrow and a scratch to his cheek on the right side of his face. V8 continued saying that V8 then came around from behind the curtain and told V5 to get out of the room then V7 assessed R1. V8 added that a few minutes later, V7 left out of R1's room and told V5 she had to leave the facility and needed to call 911 and file an incident report. During review of V8's (CNA) statement, she recalled R1 yelling out stop multiple times and heard V5 (CNA) who sounded angered saying stop it, don't put your feet on me. V8 (Certified Nursing Assistant) also said that she did not know how R1 obtained the injuries to his face, doesn't recall if they were present upon entering the room but is certain that R1 was not bleeding when she entered the room, and the injuries were not self-inflicted. V8 added that she has worked with V5 frequently but had never seen anything like this before. On 12/01/2023 at 2:40 PM, V7 (Licensed Practical Nurse) said on Thursday (11/30/2023) between 3:00-3:30 AM, she went into R1's room to provide care to R1's roommate with the assistance of V8 (CNA) and the privacy curtain was pulled all the way around the bed. She added that V5 was not in the room initially, she came into the room later. V7 then said they started to hear R1 yelling out something about is this a party, then started yelling out profanities and racial slurs and when she came around the curtain, R1 was sitting on the edge of the bed facing the door and told V7 that he kicked and slapped her, then said that she slapped me back. V7 added that she saw some bleeding near the corner of R1's left eye above the eyebrow and a red mark on his right upper cheek so she started to assess R1 and tried to stop the bleeding but R1 was resistive. She said after a few minutes, she had stepped out of R1's room, headed down the hall and told V5 that she had to leave the building. V7 then said she informed the physician of R1's bleeding and wanted to send resident out to the hospital because he is on blood thinners, but he was refusing to go. During review of V7's (LPN) statement, she then said the bleeding was to the opposite eye, and the scratch was to the opposite side of R1's face then previously stated. V7 then said at no time did she see any physical contact (which is a contradiction of her previous statement made on 11/30/2023), and the bleeding looked like old blood because it was dark. On 12/02/2023 at 12:08 PM, V1 (Administrator) said she wasn't sure if abuse screens were to be completed upon admission, but she knows they are done quarterly. At 12:11 PM, V1 said she believes the abuse screens are done upon admission but will have to check with social services. At 12:28 PM, V1 said the screenings are done quarterly with no start date given and as needed with a new diagnosis or data. V1 then said the facility was not fully aware of R1's medial/behavioral/trauma history until recently being informed by resident's family. V1 provided pre-admission behavior notes dated 11/02 and 11/03/2023 for surveyor to review. On 12/02/2023 at 12:16 PM, R1 said regarding the incident with V5 that he was lying in bed when she came into his room, started saying nasty stuff and cursing to him, came to his bedside then smacked the left side of my face (R1 pointed to injuries to corner of left eye previously observed by surveyor). R1 said he then sat up on the side of the bed when V5 started to come near him again and stated that he had kicked V5 to her chest area. R1 said that V5 then hit him to his left jaw area (displayed facial grimacing while touching area of contact). R1 added that she got me good then said he had pain and swelling to the area after it happened. Mild swelling was observed to R1's left jaw area but unable to visualize any bruising due to the presence of a thick beard. On 12/02/2023 at 12:56 PM, V1 (Administrator) and V2 (Director of Nursing) were both present and stated that the nurse who assessed R1 post fall on 11/29 at 10:10 did not fully assess or document post fall injuries/findings then said R1 was sent to the emergency room for further evaluation of the bruising he sustained from the fall. V2 then said injuries could appear on a resident days later after falling. R1's physician note created by V9 (Medical Doctor) on 12/2/2023 14:11:45 that was time stamped for 11/30/2023 14:11 reads in part, I was contacted by [registered nurse] overnight about [patient] having skin lesion to side of eye, and patient was refusing to go to [emergency room] for eval. Etiology of injury was vague. This AM, I came to eval [patient], he has mild skin abrasions on right and left side of eye, and upon further inspection with [registered nurse] at bedside, he has bruising on his wrist and torso. Per [registered nurse] management, [patient] had a fall overnight. [Patient] also did report he had some sort of altercation with a staff member, although recollection is vague given his sundowning. I instructed [registered nurse] management to send [patient] to [emergency room] for further evaluation and investigate the patient's claims. Facility provided fall documentation dated 11/29/2023 which indicated no injuries. Facility provided conflicting witness statements dated 11/29/2023 from three staff members with two statements indicating noted bruising post fall to R1's back, and one statement that indicated scratches to R1's face. No other documentation from direct care staff indicating R1 sustained any injuries, no documentation noted indicating staff were monitoring R1's bruising and/or facial injuries until 48 status post fall. Abuse Prevention and Reporting policy last revised 10/24/2022 reads in part: Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment (page 1). Definitions: Physical abuse is 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 (page 2). Resident Assessment: As part of the resident's life history on the admission statement, comprehensive care plans, and Material Data Set (MDS) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers, and behaviors that might lead to conflict (page 7).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform a physician of abnormal labs prior to a resident's change of condition of 4/03/2023 for one of thirty residents (R3) in the sample. This failure resulted in R3 having to be hospitalized due to acute hypoxemic respiratory failure, seizures, and hypernatremia. Findings Include: R3 is a [AGE] year old female who was originally admitted to the building on 7/26/2012 and still currently resides in the facility. R3 has multiple diagnoses including but not limited to the following: epilepsy, vitamin D deficiency, multiple sclerosis, severe protein calorie malnutrition, dementia, hypernatremia, hypokalemia, pressure inducted deep tissue damage, and gastrostomy. Facility lab report dated 4/3/23 shows in part but not limited to the following: blood urea nitrogen (BUN): 30 (High) and Sodium (Na): 157 mEq/L (Critically High). Facility progress note dated 4/5/23 states in part but not limited to the following: R3 was observed during rounds with twitching of the face. R3 was not responding, skin was clammy, and face was twitching. Resident was placed on a non-rebreather, 911 was called, and R3 was taken to the emergency room. Per hospital records dated 4/11/23 show in part but not limited to the following: Principal problem: acute hypoxemic respiratory failure; active problems: altered mental status, seizures, AFib, hypernatremia, and lactic acidosis. New onset seizure activity, fever, currently AFib, sepsis due to bacteremia, acute hypoxic respiratory failure 2/2 seizures, hypernatremia was 163 mEq/L upon admit. On 6/13/23 at 12:15PM, V17 (Licensed Practical Nurse) was interviewed regarding R3's incident on 4/5/23 and care. V17 said on 4/5/23, I was doing medication pass and the wound team were doing rounds. They went into R3's room and they called me into the room. I observed R3's face twitching, her skin was clammy, and she was not responding to any stimuli. We sent her out via 911. I was working the day before and nothing out of the ordinary was noted, she was fine. The labs taken on 4/3/23 may have been routine labs, I do not remember anything out of the ordinary happening with R3 prior to 4/5/23. Per facility progress note dated 4/3/23 states in part but not limited to the following: labs relayed to V16 (Nurse Practitioner), awaiting orders. On 6/13/23 at 1:46PM, V16 was interviewed regarding R3's care and recent hospitalization. V16 said right now I cover majority of the residents in the building if they are having any acute changes, however I only work on Tuesday's and Friday's. I was made aware of R3's incident after she was sent to the hospital. I looked back at my phone today and it does look as if V17 messaged me regarding R3's lab results but I do not remember. I was not working on 4/3/23 so I do not remember seeing this message. However, I definitely would have ordered something if I was made aware. I typically always provide treatment when a resident's sodium is over 150 mEq/L. I would have increased her free water flushes since she is on a gastric tube and do labs the next day. If the lab was still high the following day, I would send the resident out. High sodium levels can be an indicator of dehydration and can also cause seizures. It is to be noted that R3's physician order sheet shows no new orders put in place between 4/3/23 and on 4/5/23 when R3 was sent to the hospital. On 6/14/23 at 2:05PM, V1 (Administrator) was interviewed regarding nursing expectations for residents who are experiencing a change of condition. V1 said it is expected that the nurse reach out to the resident's primary physician, nurse practitioner, or medical director. If they do not hear back from anyone, they are to report it to the oncoming nurse before leaving their shift. They should be continually following up to ensure the appropriate parties are aware. Per facility policy titled Assessment of Resident with revision date of 4/18/22 states in part but not limited to the following: Purpose: To gather comprehensive information as a basis for identifying resident problems/needs and developing or revising an individual plan of care. Guidelines: 8. If reassessing resident, review progress notes, physician's orders and progress notes, weights, intake/output records, laboratory test results, resident's response to current treatments. 10. Notify the attending physician or significant findings and request necessary change in orders. Accordint to the National Institutes of Health: The most serious complication of hypernatremia is subarachnoid or subdural hemorrhage due to the rupture of bridging veins and [NAME] sinus thrombosis. It can lead to permanent brain damage or death. Rapid correction of chronic hypernatremia causes cerebral edema, seizure, and permanent brain damage. Sonani B, Naganathan S, Al-Dhahir MA. Hypernatremia. [Updated 2023 May 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441960/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to carry out physician's orders related to the use of a hand splint and therapy carrot (Splints/carrot prevents further contracture) for one (R7) of one resident reviewed for restorative nursing. This failure resulted in R7's left hand contracture deteriorating from moderate to severe contracture. Findings include: R7 is a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side; Vascular Dementia without Behavioral Disturbance; Contracture, Left Elbow and Contracture, Left Hand. On 08/01/2022 at 11:30 AM, R7 was observed in bed, awake, has trouble speaking and unable to verbalize needs. His left elbow was observed stiff and flexed. His left hand/wrist was also stiff, clenched into a fist and the fingers are curled inward. No splint or therapy carrot (positions the fingers away from the palm to protect the skin from excessive moisture, or further contracture) on his left hand was observed applied. V28 (Family Member) came for a visit and stated, He's (R7) been a resident here since October 2018. He had severe stroke on his left side. The only concern is his left hand, it is clenched, unable to open it. I want to ask for any orders to treat his left hand. R7's POS (Physician Order Sheet) dated 10/20/21 documented: Splints: Left hand in orange carrot for four to six hours daily as tolerated. Left hand and elbow extension splint for four to five hours as tolerated. Watch for redness, skin breakdown or pain, discontinue use and notify nursing and therapy. On 08/02/22 at 10:00 AM, R7 was observed in bed. No splint or therapy carrot were observed on his left hand. On 08/02/22 at 10:15 AM, V4 (Restorative Nurse) was asked regarding R7's restorative program. V4 replied, He has a left hand contracture. He has an order for a left hand splint but we are not placing it on him because the left hand is so contracted, he cannot tolerate the splint. Instead, we are putting the carrot in his left hand. Several months ago, we used to put a splint, restorative does it but it was discontinued. He still uses the therapy carrot. V5 (Restorative Certified Nurse Aide, CNA) is putting it every day. The carrot is stored in our office. There was no documentation in the medical record or physician orders confirming that splint for the left hand was discontinued. V5 (Restorative CNA) was asked regarding application of the carrot in R7's left hand on 08/02/22 at 10:25 AM. V5 stated, The application of the carrot stick is still ongoing, we put it in the morning and sometimes in the afternoon and it stays for two to four hours. It was placed in his hand last Friday (07/29/2022). I am responsible for the application and removal of it when done. If I am not here, then he is not going to have the carrot in his hand. I did not place it last Saturday and Sunday because I was off and yesterday I worked on the floor. We're short of staff. There is a log that I have to sign with time duration in minutes that I put the carrot in his left hand. In an interview conducted on 08/02/22 at 11:35 AM, V4 (Restorative Nurse) was asked regarding R7's left hand contracture. V4 verbalized, We used to have a Restorative Nurse but that person left, don't know exactly the date. Since then, the facility doesn't have any Restorative Nurse or Aide. I started doing the Restorative notes last 04/20/22. His left hand and fingers could still be moved, the degree of contracture was moderate at 50% normal. My assessment last month which I dated 08/02/2022, the left hand contracture was so severe, less than 50% of normal. He cannot open his fingers and move his wrist. It declined because the splint and the carrot were not continuously applied. R7's Restorative Observation Notes documented the following: 04/11/22: Splint program B. Contracture screen - left elbow: 3. Moderate 50% of normal; left hand/fingers: 3. moderate 50% of normal 07/29/22: Splint program B. Contracture screen - left elbow: 4. Severe <50% of normal; left hand/fingers: 4. severe <50% of normal OT daily treatment note dated 10/15/2021 reads: Elbow extension improved with elbow extension brace for LUE (left upper extremity). Patient displays increased active range of motion left hand. Continue with restorative nursing. OT evaluation and plan of treatment dated 07/28/2022 reads: Musculoskeletal System Assessment LUE ROM (range of motion): elbow/forearm-impaired; wrist-impaired; hand-impaired; thumb-impaired; index finger-impaired; middle finger-impaired; ring finger-impaired; little finger-impaired AROM (Active Range of Motion) - Left wrist: flexion, severe LUE contractures, allows for minimal PROM (Passive Range of Motion); extension, severe LUE contractures, allows for minimal PROM R7's Restorative logs for the splint and therapy carrot administration indicated the following: May 2022: no documentation on 05/04; 05/05; 05/09; 05/10; 05/12; 05/13; 05/14; 05/15; 05/18; 05/20; 05/21; 05/26; 05/27 and 05/30. June 2022: no documentation on 06/01 to 06/10; 06/12 to 06/15; 06/17 to 06/20; 06/22; 06/25 to 06/29. July 2022: splint program for left hand and elbow as ordered for four to six hours for six to seven times per week as tolerated. Gentle ROM to BUE (bilateral upper extremity) and place orange carrot in left hand or elbow extension splint to LUE as tolerated. No documentation on 07/03; 07/07; 07/08; 07/11; 07/12; 07/13; 07/16; 07/17; 07/22; 07/23; 07/24; 07/26; 07/28; 07/29; 07/30 and 07/31. R7's restorative logs dated May to July 2022 indicated that splint and therapy carrot were not applied daily as ordered. R7's Care Plan, date initiated 10/25/21 regarding the left hand and elbow splint/ therapy carrot, documented in part: Interventions: Establish wearing schedule: four to six hours as tolerated. On 08/03/22 at 09:52 AM, V21 (Physician) was interviewed regarding R7 and contracture. V21 stated, He is my patient. I've been taking care of R7 for a long time. R7 has a history of stroke, R7 had a right sided CVA (Cerebrovascular Accident, stroke) and has left hemiplegia (left sided weakness, paralysis), and a contracted left hand. His fingers can't be moved and are always contracted. If I give an order, it should be followed. Splints and the carrot help in preventing further decline in the contracture of the left hand. 08/03/22 at 11:51 AM, V3 (Director of Nursing) stated, If there is an order for splints or braces, the restorative nurse is responsible for carrying it out. Doctors' orders should be followed per the resident's plan of care. Splints/carrot prevents further contracture. In the log, if it is not documented, it is not done, maybe staff forgot about it but it should be documented. Facility presented policy titled Physician Orders - Entering and Processing revision date 1-31-18 when requested. The policy does not specifically address guidelines in following doctors' orders for restorative program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent residents from developing facility acquired pressure ulcers who were admitted with no previous skin alterations and are totally dependent on staff for care and repositioning. This failure applied to two (R17 and R27) of three residents reviewed for pressure ulcers and resulted in R17 developing an infected wound to her right second toe that required treatment with oral and topical antibiotics, as well as a Stage 2 pressure ulcer to her coccyx and an unstageable pressure ulcer to right ischial tuberosity; R27 developed a Stage 3 pressure ulcer on the coccyx. Findings include: R17 is a [AGE] year-old female who has resided at the facility since 12/26/2021 with past medical history including, but not limited to Dementia, major depressive disorder, weakness, other abnormalities of gait and balance, altered mental status, etc. 8/01/2022 at 11:05 AM, R17 was observed in her room sleeping and unable to wake or respond to her name. At 2:15PM, R17 was still in her bed in the same position, a floor mat was noted at the bedside, room unorganized with some garbage noted on the floor, resident was not wearing any heel protectors and no wedges were noted on the bed. 8/2/2022 at 9:52AM, R17 was observed lying-in bed, still not able to respond to any questions or open her eyes or answer any questions, again no heel protectors or wedges noted. Progress note documented by V19 (RN/wound care) reads as follows: 08/02/22 1:33 PM Wound Care: Weekly wound rounds performed by writer. During wound rounds, resident noted with open area to R (right) 2nd toe. Area cleansed w/normal saline and protective dressing applied. Area appears reddened with small amount of purulent drainage coming from wound noted. Wound MD at bedside. Resident seen and treated by Wound Care MD. Wound care orders obtained from Wound MD. Oral and topical antibiotic ordered to treat infection to R 2nd toe. Resident to start 14-day course of doxycycline 100mg bid and Bactroban topical to be applied to area bid x 14 days. Labs ordered with (company name). Protective and preventive measures to be put in place including, but not limited to, air mattress, frequent repositioning, and incontinence program, offloading, and nutritional supplements. Progress note documented on 7/08/2022 by V19 reads; Weekly wound rounds performed by writer. During wound rounds, resident noted with pressure area to Right Ischium. Area cleansed w/normal saline and protective dressing applied. Spoke with daughter, (Legal Guardian) to make aware. Unit nurse made aware. Wound Care consult in place. Wound Care Md in facility during wound rounds and consult performed. Wound care orders obtained from Wound MD. Labs and supplements ordered. Protective and preventive measures to be put in place including, but not limited to, air mattress, frequent repositioning, and incontinence program, offloading, and nutritional supplements. Review of wound list provided by V3 (DON) showed that R17 has a stage 2 pressure ulcer to her coccyx and an unstageable pressure ulcer to right ischial tuberosity (the lowest of the three major bones that make up each half of the pelvis) both wounds are facility acquired. Braden observation dated 5/13/2022 scored R17 as 13 (moderate risk) for skin breakdown. admission charting dated 4/22/2022 indicated that R17 has no skin or wound concerns. Care plan initiated 12/23/2018 and revised 8/03/2022 stated that resident has potential impairment to skin integrity due to incontinence, fragile skin, and impaired mobility. Interventions include, but not limited to encourage and assist with offloading pressure from bilateral heels while in bed, encourage and assist with turning and repositioning at regular intervals every shift. Wound care assessment detail report dated 7/8/2022 indicated that R17 has an unstageable pressure ulceration to her ischial tuberosity identified on 7/8/2022, measuring 3.70 x 2.30 x unknown (L x W x D), area 8.51cm and unknown volume. R27 is a [AGE] year-old female who has resided at the facility since 04/2021, with medical history including, but not limited to hyperlipidemia, hypertensive chronic disease, dementia, abnormal posture, weakness, contracture of left knee and right wrist, etc. 8/01/2022 at 11:48AM, R27 was observed in her bed, awake but non-verbal and could not answer any interview questions. At 2:10PM, resident was observed lying in the same position as earlier and still non -verbal, no heel boot or wedges noted on the bed. 8/2/2022 at 10:30AM, resident was observed during wound care, awake and alert but did not respond to any questions. 8/02/22 at 10:30AM observed wound care for R27 with V19 (RN) who stated that resident has a stage 3 pressure ulcer that is facility acquired. Observed a large area of healed area in the resident's bottom (coccyx) and an area of fresh wounds that is about a quarter size. V19 said that the wound was facility acquired. Per record review, R27 was readmitted to the facility on 04/2021, Braden score assessment dated [DATE] scored resident with a score of 9, very high risk for alteration in skin integrity. admission assessment dated [DATE] did not document any skin concerns. Physician order dated 4/22/2021 states, elevate boots to bilateral lower extremity to offload heels. Care plan initiated 11/18/2021 states to assess and record changes in skin status. Facility Minimum Data Assessment (M D S) dated 5/5/2022 coded R27 in section C Cognition) with a BIMS score of 3, section G (Functional) coded R27 as dependent on staff for all ADL activities, and total dependence with 2 staff physical assist for toileting. Resident developed a stage 3 facility acquired pressure ulcer identified as documented in wound note dated 7/20/2022, measuring 1.70x 2.00x 0.50 (LxWxD), area of 3.40cm and volume of 1.70cm. Wound care note dated 8/2/2022 shows a Braden score of 10 (High risk), clinical stage of wound still a stage 3, measuring 2.80 X 2.00 X 0.30 (LxWxD). Area of 5.60cm and volume of 1.68cm. 8/3/2022 at 2:13PM, V3 (DON) said that the admitting nurses do the initial skin assessment to see if residents have any wound or skin issues, Braden score is part of the admission assessment to determine if residents are prone to skin breakdown, those identified at risk have care plan in place, with interventions like air loss mattress, offloading and turning and repositioning. Skin conditions should be identified during ADL care or weekly skin checks and any type of impairment like redness should be reported to the nurse or the wound team. A facility policy presented by V3 (DON) titled pressure ulcer prevention, with a revision date of 1/15/18, states as its purpose; to prevent and treat pressure sores/pressure injury. Under guidelines, the document states in part; to maintain clean/dry skin during daily hygiene, inspect the skin several times daily during bathing, hygiene, and repositioning measures, may use lotion on dry skin. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to prevent further decline of a contracture in the hand related to the use of splint and therpy carrot for one resident (R7) of one resident reviewed for restorative program. This deficiency resulted in R7's contracture of the left hand deteriorating from moderate to a severe contracture. Findings include: R7 is a [AGE] year-old male, originally admitted in the facility on 10/02/2018 with diagnoses of Hemiplegia and Hemiparesis (paralysis, weakness) Following Cerebral Infarction (stroke) affecting Left Non-Dominant Side; Vascular Dementia without Behavioral Disturbance; Contracture, Left Elbow and Contracture of the Left Hand. On 08/01/2022 at 11:30 AM, R7 was observed in bed, awake, has trouble speaking and unable to verbalize needs. His left elbow was observed stiff and flexed. His left hand/wrist was also stiff, clenched into a fist and the fingers were curled inward. No splint or therapy carrot was in his left hand were observed. V28 (Family Member) came for a visit and stated, He's (R7) been a resident here since October 2018. He had a severe stroke on his left side. The only concern is his left hand, it is clenched, unable to open it. I want to ask for any orders to treat his left hand. R7's POS (Physician Order Sheet) dated 10/20/21 documented: Splints: Left hand in orange carrot for four to six hours daily as tolerated. Left hand and elbow extension splint for four to five hours as tolerated. Watch for redness, skin breakdown or pain, discontinue use and notify nursing and therapy. On 08/02/22 at 10:00 AM, R7 was observed in bed. No splint or therapy carrot were observed on his hand. On 08/02/22 at 10:15 AM, V4 (Restorative Nurse) was asked regarding R7's restorative program. V4 replied, He has a left hand contracture. He has an order for a left hand splint but we are not placing it on him because the left hand is so contracted, he cannot tolerate the splint. Instead, we are putting the carrot in his left hand. Several months ago, we used to put a splint, restorative does it but it was discontinued. He still uses the carrot. V5 (Restorative Certified Nurse Aide, CNA) is placing it every day. The carrot is stored in our office. There was no documentation in the medical record or physician orders confirming that splint for the left hand was discontinued. V5 (Restorative CNA) was asked regarding application of the carrot in R7's left hand on 08/02/22 at 10:25 AM. V5 stated, The application of this carrot stick is still ongoing, we put it in the morning and sometimes in the afternoon and it stays for two to four hours. It was placed on his hand last Friday (07/29/2022). I am responsible for the application and removal of it when done. If I am not here, then he is not going to have the carrot placed in his hand. I did not place it last Saturday and Sunday because I was off and yesterday I worked on the floor. We're short of staff. There is a log that I have to sign with time duration in minutes that I put the carrot in his left hand. At 10:45 AM, surveyor asked V5 to show how the therapy carrot is placed in R7's left hand. V5 cleaned his left hand with wipes and carefully inserted the therapy carrot. It was observed that his hand and fingers were very stiff and difficult to stretch. Gradually, V5 was able to insert the carrot. V5 verbalized, It stays for two to four hours, most of the time, only two hours. R7's Care Plan, date initiated 10/25/21 regarding left hand and elbow splint/therapy carrot, documented in part: Interventions: Establish wearing schedule: four to six hours as tolerated. 08/02/22 at 11:35 AM, V4 (Restorative Nurse) was asked regarding R7's hand contracture. V4 verbalized, We used to have a Restorative Nurse but they left, don't know exactly the date. Since then, the facility doesn't have a Restorative Nurse. I started doing the Restorative notes last 04/20/22. His left hand and fingers could still be moved, the degree of contracture was moderate at 50% of normal. My assessment last month which I dated 08/02/2022, the left hand contracture was so severe, less than 50% of normal. He cannot open his fingers and move his wrist. It declined because the splint and the carrot was not continuously applied. He was referred for Occupational Therapy. R7's Restorative Observation Notes documented the following: 04/11/22: Splint program B. Contracture screen - left elbow: 3. Moderate 50% of normal; left hand/fingers: 3. moderate 50% of normal 07/29/22: Splint program B. Contracture screen - left elbow: 4. Severe <50% of normal; left hand/fingers: 4. severe <50% of normal OT daily treatment note dated 10/15/2021 reads: Elbow extension improved with elbow extension brace for LUE (left upper extremity). Patient displays increased active range of motion left hand. Continue with restorative nursing. R7's Restorative logs for the splint and therapy carrot administration indicated the following: May 2022: no documentation on 05/04; 05/05; 05/09; 05/10; 05/12; 05/13; 05/14; 05/15; 05/18; 05/20; 05/21; 05/26; 05/27 and 05/30. June 2022: no documentation on 06/01 to 06/10; 06/12 to 06/15; 06/17 to 06/20; 06/22; 06/25 to 06/29. July 2022: splint program for left hand and elbow as ordered for four to six hours for six to seven times per week as tolerated. Gentle ROM to BUE (bilateral upper extremity) and place orange carrot in left hand or elbow extension splint to LUE as tolerated. There was no documentation on 07/03; 07/07; 07/08; 07/11; 07/12; 07/13; 07/16; 07/17; 07/22; 07/23; 07/24; 07/26; 07/28; 07/29; 07/30 and 07/31. R7's restorative logs dated May to July 2022 indicated that splint and therapy carrot were not applied daily as ordered. 08/02/2022 at 3:46 PM, V20 (Occupational Therapist) was interviewed regarding R7's therapy evaluation. V20 stated, I did the evaluation on his left hand on 07/28/2022. He had a left hand contracture. He was not able to actively do it by himself with the whole upper left extremity. It had to be passive range of motion. The orange carrot helps to stretch the hand and that would hopefully reduce the contracture. The splint also reduces the contracture and prevent further decline or deformity of the hand. OT evaluation and plan of treatment dated 07/28/2022 reads: Musculoskeletal System Assessment LUE ROM (range of motion): elbow/forearm-impaired; wrist-impaired; hand-impaired; thumb-impaired; index finger-impaired; middle finger-impaired; ring finger-impaired; little finger-impaired AROM (Active Range of Motion) - Left wrist: flexion, severe LUE contractures, allows for minimal PROM (Passive Range of Motion); extension, severe LUE contractures, allows for minimal PROM 08/03/22 at 9:52 AM, V21 (Physician) was interviewed regarding R7 and contracture. V21 stated, He is my patient. I've been taking care of him for a long time. He has a history of stroke, had a right sided CVA (Cerebrovascular Accident, stroke) and left hemiplegia (paralysis, weakness), and a contracted left hand. His fingers can't be moved and are always contracted. If I give an order, it should be followed. Splints and the carrot help prevent further decline in the contracture of the left hand. 08/03/22 at 11:51 AM, V3 (Director of Nursing) stated, Restorative Aides are the ones applying the splints or carrot sticks. If restorative nurse and aides are not here, the nurses on the floor are trained to apply the devices. The splints/braces should be kept at bedside. Splints/carrot prevents further contracture. In the log, if it is not documented, it is not done, maybe staff forgot about it but it should be documented. Facility's policy titled, Restorative Nursing Program, revision date 1-4-19 stated in part but not limited to the following: Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but is not limited to, programs in walking/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs.