**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, observations, and interviews, the facility failed to follow physician orders for wound treatments and failed to ensure qualified staff provided wound assessments and treatments for 1 of 3 residents reviewed for wounds and wound care (Resident # 16). The facility also failed to complete regular smoking assessments for Resident #31. The facility reported a census of 41 residents at the time of the survey. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool dated 1/17/22, Resident # 16 scored 3 of 15 possible points on the Brief Interview for Mental Status, which meant the resident demonstrated severely impaired cognitive abilities. The MDS identified the resident as at risk for pressure ulcers with 1 venous/arterial ulcer, and open lesion. The MDS documented the resident received wound treatments including the application of non-surgical dressings, ointments and dressings to feet. The electronic medical record listed Resident # 16's medical diagnoses which included peripheral vascular disease (PVD), venous insufficiency, personal history of transient ischemic attack (TIA or mini-stroke), cerebral infarction, open wound right lower leg, and Alzheimer's disease. Resident # 16's care plan identified or initiated on 9/8/21 an actual alteration in skin integrity related to PVD/venous insufficiency. The care plan documented a goal: skin alterations will resolve with treatment over the next review period. The care plan directed staff to implement interventions that included: giving medication as appropriate, following treatment instructions, providing a balanced diet to promote wound healing, assessment by the dietician if appropriate, and follow physician's instructions. The care plan also included Resident #16's potential for a self-care deficit related to Alzheimer's dementia with severely impaired cognitive functions including maintaining good hygiene. The care plan directed staff members to follow treatments as ordered. The facility's Skin Management Protocol dated 10/14/21, directed staff to notify the Clinical Quality Team if the skin ulcer or non-ulcer has not made improvements after the first two weeks. The existing orders from 2/24/22 through 4/6/22 related to Resident # 16's wound management directed: A. Pro Stat Liquid Amino Acids Protein Hydrolysis Give 30 ml [milliliters] by mouth once a day for wound healing (ordered on 10/16/21). B. Desitin Rapid Relief Cream 13% (Zinc Oxide), apply to right medial ankle every 72 hours. Apply Desitin mixed with collagen powder to peri-wound related to unspecified open wound on the right lower leg, cover with Optilock dressing, and wrap with Kerlix. Change every 3 days and as needed (ordered for 2/24/22 to 3/14/22). C. The Wound Treatment Plan dated 3/11/22 and noted by Staff B, directed staff to cleanse (the area) with wound cleanser, apply a large sheet of calcium alginate, cover with Optilock, and wrap with Kerlix. Change 3 x [times]/week and PRN [as needed]. However, the medication administration record (MAR) directed staff to provide the wound treatment every 3 day(s) and as needed, contrary to the Wound Treatment Plan, D. The Wound Treatment Plan dated 4/1/22, directed staff to Please cleanse with wound cleanser, apply triamcinolone cream to all eurhythmic areas, and then apply a sheet of calcium alginate, cover with Optilock, wrap with Kerlix. Change 3 x/week and PRN. In an observation on 4/5/22 at 11:12 AM, Resident # 16 walked slowly and in an awkward manner in the hallway of the CCDI (Chronic Care and Dementing Illness) unit toward the dining room for lunch. A closer observation of Resident # 16's right ankle revealed it wrapped with a white dressing that appeared dirty and soiled with a yellowish to brownish substance On 4/6/22 at 2:51 PM, observations for dressing change on Resident # 16's right medial ankle showed the following: A. Staff A, Certified Medication Aide (CMA) was in Resident # 16's room to assist Staff B Registered Nurse (RN) provide the dressing change. Staff A slowly unwrapped the wound area by removing the soiled Kerlix (bandage gauze) dressing which emitted a foul odor into the room. The outermost dressing (Kerlix) was very dirty with brownish wound drainage and Staff A verified that the dressing was very soaked. The poor condition of the dressing and the foul odor prompted inquiry as to when dressing was last changed, and if the dressing change procedure included writing a date on the top dressing, Staff A replied that dressings were dated but verified that Resident # 16's old dressing that was just removed did not contain a date. B. Staff B removed the alginate (wound dressing used to absorb exudates) dressing, which broke apart as Staff B lifted the dressing and removed it from direct contact with the moist wound surfaces. C. Staff A sprayed the wound/skin areas with wound cleanser as directed by Staff B. D. Staff B picked up a medication tube labeled, Clobetasol 0.5% ointment apply to left forearm, and squeezed out ointment contents, and applied it all over the wound areas on Resident #16's right medial ankle. E. When asked to verify the label of the ointment medication tube/container, Staff A read, Clobetasol 0.5% and verified with Staff B. Staff B reported that the ointment medication was applied to Resident # 16's wound on right ankle according treatment order and also stated that the wound treatments and dressing changes are being done every 3 days and PRN [As needed] when the dressing gets soaked. Staff B also verified that Resident # 16's dressing today was very soaked prior to change. On 4/7/22 at about 10:45 Am, the Director of Nursing (DON) provided the package insert (prescribing information) for the Clobetasol 0.5% which described it as a potent corticosteroid indicated for the relief of swelling and itching such as in dry and scaly skin conditions, eczema, and discoid lupus erythematous. The information directed that ointment was especially appropriate for dry or scaly lesions. Resident # 16's Medication/Treatment Administration Record or MAR and progress notes from 2/27/22 through 4/6/22 revealed Resident 16's consistent and ongoing refusal of nutritional supplement ordered for wound healing; treatment orders for wound on right medial ankle were not followed; and an unqualified staff member provided the treatments, as follows: A. Pro Stat Liquid Amino Acids Protein Hydrolysis (Protein supplement clinically proven for wound healing) Give 30 ml [milliliters] by mouth once a day (10/16/21): -January 2022, Resident # 16 took the Protein supplement for 4 days (1/3, 1/10, 1/20 and 1/31) only, but refused for the other 27 days of the month; -February 2022, Resident # 16 took the Protein supplement for 3 days (2/7, 2/14, and 2/28) but then refused for the other 25 days of the month; -March 2022, Resident # 16 took the Protein supplement for 5 days (3/13, 3/21, 3/22, 3/26, and 3/28) but refused the other 26 days of the month; and -April 2022 (1-6), Resident # 16 only took the Protein supplement for 1 day (4/2/22) but refused on the other 5 days. Review of the aforementioned documents revealed a lack of documentation to show and evaluation or review of Resident # 16's ongoing refusal of the protein supplement, in order to develop or address the ongoing ineffective intervention. B. Apply Desitin Rapid Relief Cream 13% (Zinc Oxide) to right medial ankle every 72 hours (2/24/22 to 3/14/22): -On 2/27/22, Staff W Registered Nurse (RN) completed Resident # 16's wound treatment as indicated in the progress notes. -On 3/2/22, Resident # 16 refused treatment, as documented. -On 3/5/22 (on the 6th day after the last treatment provided), Staff W completed the treatment and documented in the progress notes. -On 3/8/22, Resident # 16 refused treatment. -On 3/11/22 (on the 6th day from the last treatment provided), Staff W completed the treatment as documented in the progress notes. Resident # 16's wound dressing changes and treatments were completed every 6 days from 2/27/22 to 3/11/22. The record lacked documentation of other interventions and/or an evaluation or action taken related to the treatment refusals. C. Cleanse the wound with cleanser, apply large sheet of calcium alginate, cover with Optilock, wrap with Kerlix and change 3 x/week and PRN. The dressings were not changed according to treatment plan/orders, instead, for the period reviewed (3/11/22 to 4/6/22), the dressings were changed for 4 times (excluding CMA's) out of 26 days, on the following dates: -On 3/22/22, completed as documented in the MAR; -On 3/25/22, Staff S completed the treatment as noted in the MAR; -On 3/28/22, the Assistant Director of Nursing (ADON) completed a dressing change as noted in the MAR; -On 3/31/22, Staff A, (CMA) completed the dressing change as noted in the MAR; -On 4/6/22 or 6 days after Staff A's completed the dressing change, and 9 days after the ADON did the dressing change, Staff B with assistance from Staff A, completed the dressing change and applied the (Clobetasol 0.5%) ointment medication (indicated for dry areas) to a draining wound without an order during the observation on 4/6/22 beginning at 2:51 PM. D. Apply triamcinolone cream to eurhythmic areas (4/1/22): -Observation on 4/6/22 showed that Staff B failed to apply this medication. On 4/7/22 at 3:54 PM, the DON verified that the facility's policy is not specific to wound treatment procedures and did not identify who should be performing the dressing changes. However, the DON reported that assessments and treatments are nursing responsibilities and added that she expected nurses to complete wound treatments (such as Resident # 16's vascular wound). The DON verified that Resident # 16's wound was first identified in 9/21, saying, The wound has been there for a while. The DON also stated she expected staff to follow treatment plan/orders and said dressings to weeping wounds such as Resident # 16's vascular wound dressing should not go unchanged for longer than the maximum period ordered, and to check the condition of dressings and change as needed. The DON further stated if confused residents refused treatments, she expected staff to re-approach the resident and document all actions taken in the residents' medical records. On 4/11/22 at 10:05 AM, the Wound Nurse/Nurse Practitioner (NP) verified they come to the facility every Friday and measured the wounds but did not provide any wound treatments when visiting. The NP verified they recommend the treatments and the facility implements them. The NP added they did not know what happened after they unwrap the wound for the assessment and stated they were not aware of the facility's procedures for wound dressing changes and documentation. During inquiry if wound healing could be delayed for failure of staff members to follow treatment orders, the NP answered, yes, potentially. Review of the progress notes completed by the above Wound Nurse/Nurse Practitioner (NP) revealed the following Skin Inspection documentation related to Resident #16's right medial ankle venous stasis ulcer: - 03/11/22: the wound measured 8.2 cm long x 5.7 cm wide x 0.1 cm deep and unable to assess wound bed. Tissue 15% macerated epithelial, 85% slough. The wound drained yellow to serous, heavy to thin drainage with no odor. - 03/18/22: the wound measured 22 cm x 12 cm x 0.1 cm, wound bed contained slough and epithelial, tissue 20% slough, 80% macerated epithelial exudate and periwound margins macerated. The wound drained yellow to serous, heavy to thin drainage with a foul odor. -03/25/22: the wound measured 16 cm x 28.5 cm x 0.1 cm, wound bed contained slough and epithelial, tissue 15% slough, 85% macerated epithelial and periwound margins macerated. The wound drained yellow to serous, heavy to thin drainage with a foul odor. - 04/01/22: the wound measured 15 cm x 30.1 cm x 0.1 cm, wound bed contained slough and erythemic epithelial, tissue 20% slough, and 80% macerated epithelial exudate and periwound margins macerated. The wound drained yellow to serous, heavy to thin malodorous drainage. 04/20/22 11:56 PM the Medical Director (MD) stated that he absolutely expects the facility to follow and implement treatments recommended by wound nurses including the frequency of treatments/dressing changes and the application of the correct medications. The MD said that in cases when residents frequently refuse treatments, staff should notify him so that the team can address the problem/s with a different plan. When asked if the wound could have healed or improved sooner if treatment orders have been followed, the MD replied, I totally understand! 2. The annual MDS assessment tool dated 6/17/21 revealed Resident #31 utilized tobacco. The care plan initiated on 6/3/19 with a revision date of 10/6/21 documented a goal for the resident to remain safe over the next review period and directed staff to allow Resident #31 to smoke with supervision in designated smoke area, and specified the resident could smoke one cigarette during smoking times but could have an extra cigarette if having behaviors to calm him down as needed. On 4/4/22 the facility provided a list of residents that smoked cigarettes which included Resident #31's name. On 4/06/22 at 10:12 AM, Resident #31 smoked with staff supervision in the facility's designated smoking area. A smoking assessment dated [DATE] revealed Resident #31 smoked 2-5 cigarettes per day and could light his own cigarette. The clinical record did not contain any follow-up or additional or regular smoking assessments for Resident #31 since 3/18/20. During an interview 4/06/22 at 11:09 AM, the Director of Nursing verified no smoking assessments completed quarterly as expected for Resident # 31 since 3/18/20 and added the MDS nurse usually completed them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 4/7/22 at 8:39 AM revealed Staff B, Registered Nurse (RN) gathered items from the treatment cart located in the north hallway in which resident's reside, left the treatment cart unlocked and proceeded into a resident's room without locking the treatment cart. During an interview on 4/7/22 at 9:04 AM the Nurse Consultant acknowledged the treatment cart had been left unlocked and unattended in a resident area. The Nurse Consultant stated she expected staff to lock the med cart when leaving it unattended. During an interview with the Director of Nursing (DON) 4/13/22 at 10:50 AM she revealed the facility does not have a policy or protocol concerning locked medication or treatment carts. 2. The electronic medical records showed Resident # 4's admission date of 1/15/18 with medical diagnoses including pseudobulbar affect, vascular dementia with behavioral disturbance, anxiety disorder due to known physiological condition, and major depressive disorder. Resident # 4 lives at the facility's Chronic Care and Dementing Illness (CCDI) unit. The quarterly MDS (minimum data set) dated 10/5/21 indicated Resident # 4's severe cognitive impairment with a BIMS (brief interview for mental status) score of 0. The MDS also indicated Resident # 4's functional status for ADLs (activities of daily living) as follows: independent for bed mobility; supervision/set up for transfers, ambulation in room and corridor, and eating; and limited assistance/1 person for dressing and toilet use. The care plan with last revision date of 6/12/21, showed that Resident # 4 had a potential for injury related to dementia with behavioral symptoms such as inability to always recognize own physical limitations, impairment of balance, and alteration in gait. The care plan goal was for Resident # 4 to not sustain any serious injury from a fall throughout review period. The plan of actions/interventions at the time included: facility to follow fall protocol with occurrences, pharmacy consult to evaluate medications and make recommendations as indicated, and for staff to encourage to call for assistance as needed. Observations indicated Resident # 4's fall risk include: On 4/4/22 at 2:01 PM, Resident # 4 was observed in her room with walker and walking over fall mattress on the floor below bed. Staff K Registered Nurse (RN) and Staff G Certified Nurse Aide (CNA) entered Resident # 4's room and then Staff K stepped out to take a wheelchair from the hallway and assisted Resident # 4 on it. On 4/6/22 at 2:06 PM, Resident # 4 was in the TV room with multiple attempts to stand up from wheelchair. Resident # 4 asked Staff R CNA if he/she could sit in the regular chair. Staff G CNA and Staff R assisted Resident # 4 from wheelchair to regular chair, but after about 2 minutes, Resident # 4 then asked staff if he/she could go to his/her room. Staff G sat with Resident # 4 in the TV room. The progress notes revealed the following: A. On 12/1/21 Resident # 4 had a fall with timeline documented as follows: -At 6:15 PM, Resident # 4 had an unwitnessed fall and was found on floor in a sitting position next to bed and complained of pain on left wrist. Resident # 4's left upper extremity had weak grip, unable to wave, with slight swelling noted on lateral side of wrist, unable to make a fist, and continued to voice discomfort; -At 6:30 PM, the swelling on left wrist increased with non-verbal cues of discomfort; -At 6:45 PM, left wrist continued to increase in swelling and Resident # 4 voicing more discomfort; -At 7:00 PM, staff notified the on-call physician, who ordered to send Resident # 4 to the hospital ER (emergency room) for evaluation and treatment; -At 7:45 PM, 2 EMTs (emergency medical technicians) arrived via ambulance and took Resident # 4 to the hospital. B. On 12/2/21 at 12:35 AM, Resident # 4 returned to facility from the hospital (Mercy One ER). The hospital nurse reported that Resident # 4 had diagnosis of acute distal ulna fracture with splint in place and not to be removed until follow-up care appointment with orthopedic doctor. The directions regarding Resident # 4's care from the ER, reiterated the orders including: 1-Splint to remain in place until evaluated by [orthopedic doctor] 2-call for appt [appointment] with [orthopedic doctor] for further eval [evaluation] and treatment of fracture at Mercy One [NAME] Orthopedic [address] 3-return to ED [emergency department] if symptoms worsen[.] C. On 12/2/21 at 9:17 AM, Resident # 4's appointment was set with the orthopedic clinic for December 6 at 0910 for further films and to be seen by physician. D. That on succeeding days following the fall, Resident # 4 continued to manifest restlessness and kept moving left hand, and showed indications of discomfort related to fractured left wrist, as documented on the following dates: - On 12/2/21 at 6:52 PM, numerous attempts to elevate fractured left wrist, forgetful to use call light for assistance at times and will stand up at bedside and yell for assist (sic) to BR [bathroom]. - On 12/3/21 at 7:05 AM, voiced discomfort on left wrist, 1-3 digits with purple discoloration and swollen, unable to assess 4-5 digits with splint starting from above mid-fingers to mid-forearm, with capillary refill < (less) than 3 seconds (indicating poor perfusion). -On 12/3/21 at 14:51 PM, the left wrist continued to have increased bruising on exposed fingers that were also puffy. -On 12/5/21 at 00:14 AM, with limited movement on left arm. -On 12/5/21 at 4:44 PM, numerous episodes of self transfers over the weekend even though educated numerous times to have staff assist. -On 12/5/21 at 4:46 PM, the left hand fingers continue with much bruising, slightly cool, blanche quickly, reports some discomfort to fingers. However, the progress notes and other documents reviewed with corresponding interviews related to said records also showed the following: A. Missed initial appointment for orthopedic evaluation: i) Despite the documented assessments (D) above, there lacked evidence (Resident # 4's electronic progress notes, hard chart, & other facility records) to show that Resident # 4 went for orthopedic evaluation on 12/6/21 at 9:10 AM, as ordered and set on 12/2/21. There also lacked evidence to show the reasons behind Resident # 4's missed appointment. The progress notes entered on 12/6/21 at 1:30 PM or 4 hours after the intended appointment time, indicated that the said appointment (orthopedic evaluation) was reset for 12/20/21 at 9:40 AM and with instruction for Resident # 4 to arrive an hour prior to appointment time. In addition, there lacked evidence to show Resident # 4 ever had to return to ED for worsening symptoms as ordered on 12/2/21. ii) On 4/12/22 at 9:44 AM, Staff S, Licensed Practical Nurse (LPN) stated he/she works as a PRN (as needed) staff member and at times would take care of Resident # 4 when working. Staff S said that he/she has no idea why Resident # 4 did not go to the orthopedic appointment on 12/6/21. iii) On 4/12/22 at 12:56 PM when asked if Resident # 4 missed an appointment for evaluation by the orthopedic doctor on 12/6/21 at 9:10 AM and what caused Resident # 4 to miss the said appointment, the Assistant Director of Nursing (ADON) replied, I don't remember, it must have been transportation or they canceled. I am not sure. The ADON checked through her computer and verified that Resident # 4 did not go for the orthopedic evaluation and verified lack of documentation regarding the rationale for the missed appointment. When clarified if the orthopedic clinic was the one that canceled the appointment, the ADON then said, I remember calling Iowa Ortho asking them if they really want another film taken because [Resident # 4] was just in the ER. The ADON added that the clinic returned call saying does not need one and will be seen on the 20th [December]. iv) On 4/14/22 at 3:15 PM, Orthopedic Clinic Registered Nurse (OC RN) verified that according to their record, Resident # 4 had an appointment on 12/6/21 at 9:10 AM for evaluation with Dr. MG but was canceled. OC RN reported that their records do not show reason behind the cancellation. When inquired if the orthopedic clinic cancels orthopedic evaluation appointments for patients with fracture and showing signs of restlessness and discomfort, OC RN replied that the only reason they would cancel any appointment is when they have to close due to bad weather or the particular doctor is ill. OC RN also verified that the orthopedic clinic was open and Dr. MG was present for work on 12/6/21. v) The progress notes showed that Resident # 4 went for the orthopedic evaluation on the reset date of 12/20/21 (19 days after onset of injury), wherein the orthopedic physician then replaced Resident # 4's wrist splint with a cast. The orthopedic physician's orders included ensuring Resident # 4 to be non-weight bearing on left wrist until follow up; not to get cast wet; and to continue to monitor. B. Discrepancies of information in Self Report investigation document from that obtained from survey interviews and review of other pertinent documents, as follows: i) The Self Report documented the following: -That Resident # 4 was found on the floor next to bed in a sitting position by Staff R; -That Resident # 4 was assisted back to bed by Staff S and Staff R using a gait belt; -That a bedside table with her drinks and snacks within reach when the incident occurred; -That on 12/1/21 from 6:05 PM through 6:45 PM, Resident # 4 was able to fully move left wrist, with no increase in pain, and no obvious injury noted; -That Dr. Min Pak completed a Major Injury Determination Form and declared Resident # 4's injury as not major; -That Resident # 4 required assistance of 1 for all transfers and ambulation with a wheeled walker, and assisted by 1 staff for all ADLs. ii) The interviewees' statements contrary to the above Self Report information, are as follows: On 4/12/22 at 9:15 AM, Staff H (LPN) stated he/she was the oncoming nurse on 12/1/21 when Resident # 4 had a fall with a fractured left wrist. Staff H stated that her assessments prompted him/her to send Resident # 4 to the hospital and said, I don't remember details so many things happened, and that was a long time ago. It should be in the progress notes. Staff H reported, [Resident # 4] was independent in room and in the hallways and assist with cares at the time of the incident. On 4/12/22 at 9:44 AM, Staff S stated that he/she was the outgoing nurse that evening on 12/1/21 when Resident # 4 fell at about 5 minutes to 6:00 PM. Staff S said he/she was giving report to the oncoming nurse at that time when notified about the fall. Staff S said that by the time he/she entered Resident # 4's room, Resident # 4 was already up and sitting by the side of bed accompanied by Staff U, Temporary Nurse Aide (TNA). Staff S stated Staff U who was new and not yet certified as an aide at that time, transferred Resident # 4 from the floor to sit on the bed side. Staff S said that Resident # 4 was complaining of left hand pain during assessment, and that he/she educated Staff U about not transferring residents after a fall, until after a nurse's assessment. Staff S denied having a hand in transferring Resident # 4 from the floor to bed. Staff S also stated that Resident # 4 was independent in room prior to the incident. On 4/12/22 at 1:00 PM, when clarified if Staff S and Staff R assisted Resident # 4 from the floor to sit on bed, Staff S reiterated that Staff U helped Resident # 4 and identified Staff R Certified Nurse Aide (CNA) as the one who went to get Staff S. However, when Staff arrived in the room Resident # 4 was already sitting on the side of the bed. On 4/12/22 at 1:54 PM, Resident # 4's family members who were visiting said that they are not satisfied with the facility's interventions regarding Resident # 4's falls. They said that Resident # 4 continues to keep falling with 2 falls in the last week. Family Member # 3 (FM) said, Frustrating is all I can say. On 4/12/22 at 2:07 PM, Staff R reported that on 12/1/21, he/she was working at the CCDI unit with another CNA named Staff L. Staff R stated that however another aide named [Staff U] came over to pick something/supplies, I'm not sure but she beat me to [Resident # 4's] room and by the time I got in there, [Resident # 4] was already up. When asked if he/she helped, Staff R answered, No. I did not help pick [Resident # 4] up. On 4/12/22 at 3:30 PM, Staff U (CNA) reported to have worked at the facility for 6 months since 9/21, and that he/she remembered Resident # 4's fall on 12/1/21 because he/she was the one who first responded and found Resident # 4 on the floor in [Resident # 4's] room. Staff U elaborated finding Resident # 4 lying and not sitting on the floor, with lunch tray beside [Resident # 4] on the floor. Staff U reported getting Resident # 4 up by him/herself saying, I grabbed [Resident # 4] under the armpits and guide her up. Staff U also reported not using a gait belt to assist Resident # 4 up from floor. Staff U said that Resident # 4 was independent and walks on her own and a gait belt is not needed. Staff U stated, I picked [him/her] up slowly. Staff U further reported that Resident # 4 was complaining of hurting on left wrist and was changing colors and broken like that so sent [him/her] out. When asked if there was something that should have been done differently, Staff U replied, No. I think everything was done correctly. iii) The progress notes or nurse's assessment notes from 6:05 PM to 6:45 PM on 12/1/21 indicated that Resident # 4 had increased pain, swelling, and inability to move left wrist (timeline of fall assessments documented in A above), which is inconsistent with Self Report information. iv) The quarterly MDS dated [DATE] indicated Resident # 4 was independent for bed mobility; supervision/set up for transfers, ambulation in room and corridor, and eating; and limited assistance/1 person for dressing and toilet use only, which is also in conflict with Self Report information. C. Failure to conduct thorough investigation as revealed by the following: i) Aside from the discrepancies of the information contained in the Self Report document, it also did not identify all the staff members who intervened in managing Resident # 4's fall on 12/1/21 to include Staff U, who was a TNA at that time. ii) The Self Report also did not include documented orders from the hospital ED on 12/2/21 including directions to send Resident # 4 to the ED for increasing symptoms, and to set up appointment for orthopedic evaluation, which the facility set up to happen on 12/6/21 but was canceled. iii) On 4/12/22 at 9:44 AM, Staff S stated not having talked to anybody about the fall. Staff S stated that he/she only works PRN (as needed) and does not work at the facility all the time, but Staff S reported that there was some miscommunication about follow-up and x-ray. Staff S stated that the information should be in the chart. iv) On 4/13/22 at 3:13 PM, Staff U acknowledged that he/she was a TNA at the time of Resident # 4's fall on 12/1/21. Staff U also acknowledged that without first waiting for the nurse to assess, he/she transferred Resident # 4 from the floor to bed, by him/herself and without using a gait belt. Staff U reported that Staff S told him/her not to transfer and to wait for the nurse first but after it [fall] happened and Staff U further said that at that time, I did not know. Staff U said that except for Staff S's reminder about waiting for the nurse following a fall, there was no other education or training after Resident # 4's fall. Staff U reported that nobody else talked or inquired from him/her about the incident. v) On 4/13/22 at 4:01 PM, Staff R said he/she was not sure about the facility's incident investigation process saying, [Resident # 4's] fall was the first incident I was involved in with an injury but nobody talked to me about the fall aside from you [surveyor]. D. Inaccurate and incomplete information provided to the Medical Director (MD) for determination of extent of injury: i) The document titled, Major Injury Determination form dated 12/2/21 noted, [Resident # 4 went to sit up on the side of [his/her] bed when the sheets came off the mattress causing [him/her] to fall on the floor. The report also identified Resident # 4 as independent for bed mobility and assist with all ADLs. Based on the foregoing information, the MD determined that the injury sustained was not major and that Resident # 4 could return to previous functional status. ii) The did not include important details related to the circumstances of the incident such as that Staff U, TNA transferred Resident # 4 from the floor to bed without first waiting for nursing assessment and without using a gait belt; that Resident # 4 required supervision/set up only for transfers, and ambulation at the time of the incident; and that a wrist splint was to be in place until evaluated by orthopedic physician. F. Decline in Resident # 4's ADLs: i) The significant change MDS dated [DATE] indicated that Resident # 4 required supervision/1 person physical assistance for bed mobility, and limited assistance/1 person physical assistance for transfer and ambulation, and extensive assistance/1 person physical assistance for dressing, personal hygiene, and toilet use. On 4/13/22 at 10:59 AM, the Director of Nursing (DON) acknowledged that it is not safe to be transferring residents who fall without first completing assessments. The DON also acknowledged the importance of thorough investigation of incidents to establish root causes and in order to develop action plans to prevent or minimize re-occurrence of the same or similar incidents. On 4/20/22 at 11:56 PM, the MD called and clarified that the determination of not major injury related to Resident # 4's wrist fracture on 12/2/22 meant that once it [injury] healed Resident # 4 can go back to previous functional status. The MD said that a major injury means something that would make the person crippled. The MD acknowledged that complete and accurate information is very important and stated expectations that facility staff to do thorough investigation of incidents and to always document these in residents' records. The MD reported that he never saw Resident # 4 and said, I do not know the investigation that they did pertaining to Resident # 4's fall. The MD further stated that if they did not identify important details and did not document what actually transpired then I will call them right now and tell them. 3. On 4/5/22 beginning at 12:30 to 1:08 PM, Resident # 24 was walking in the hallway with a walker, proceeding to sit in a chair at the TV room, standing up again after about 10 minutes and telling staff members about wanting to go home. Resident # 24 manifested repetitive abnormal movements of tongue for the duration of the observations. The facility's matrix provided to surveyors on 4/4/22, identified Resident # 24 with fall/s, and on antipsychotic and antidepressant medications. The electronic medical records showed Resident # 24's admission date of 7/26/17 with medical diagnoses including Alzheimer's disease, paranoid schizophrenia, vascular dementia with behavioral disturbance, unspecified convulsions, and personal history of traumatic brain injury. The quarterly MDS dated [DATE], indicated that Resident # 24 required assistance with ADLs as follows: extensive and 2-person physical assistance for bed mobility; limited and 1-person physical assistance for transfers; supervision and set-up only for ambulation in room, corridor, and on unit; extensive and 1-person physical assistance for dressing, eating, and personal hygiene. Resident # 24's care plan initiated on 8/15/17, indicated risk for falls with potential for injury related to Alzheimer's disease, vascular dementia, schizophrenia with altered safety awareness and with altered gait. The care plan noted a goal for Resident # 24 to not sustain serious injury due to a fall. The care plan directed staff to: provide walker for ambulation; anticipate and meet the resident's needs; ensure appropriate footwear; do frequent checks; remove items from room that may potentially be placed in the toilet and cause a flood; and follow fall protocol. The physician's orders show use of psychotropic medications including: sertraline 100 milligrams (mg) 2 tablets by mouth 1 time a day; Depakote sprinkles capsule delayed release 250 mg by mouth 3 times a day; Seroquel 25 mg by mouth 1 time day; Seroquel 12.5 mg 1 time a day; Remeron 7.5 mg 1 time a day; and Seroquel 50 mg 1 time a day. Resident # 24's Medication Administration Record (MAR) showed a change of medication dosage from the 6/2020 record to the 7/2020, indicating a reduction of Seroquel from a total of 100 mg daily to 87.5 mg daily. The pharmacy review notes/recommendation for 2021 showed an entry dated 10/7/21, which noted, No changes recommended at this time - want to wait until [Resident # 24's] healed from surgery before GDR [gradual dose reduction] that indicated Resident # 24 had a major injury. The following document revealed Resident # 24's fall with major injury: A. The facility's Self Reports log was requested for review, which revealed Resident # 24's fall on 8/16/21. The facility's documentation regarding Resident # 24's fall contained in the Self Report document, indicated the following: -That Resident # 24 had a fall on 8/16/21 at 1:30 AM and that Staff L found Resident # 24 lying on the floor near closet; -That head to toe assessment showed right femur edematous; -That at 1:50 AM, the on-call physician ordered transfer to the hospital for evaluation of injury, and was taken to MercyOne [NAME]. The report indicated that Resident # 24 was transferred from MercyOne [NAME] to MercyOne Des Moines Medical Center and was admitted for displaced right peri-prosthetic femoral fracture; -That Resident # 24 was independent with transfers. However, review of other pertinent documents (progress notes, MDS assessments) and interviews showed inconsistency with or do not reflect the contents of the facility's Self Report document as noted in the preceding paragraph (A) above, as follows: A. The progress notes lacked entries regarding assessments and/or interventions related to Resident # 24's fall with major injury on 8/16/21. The progress notes for 8/16/21 only showed an entry at 2:03 PM indicating that Resident # 24 was sent to the hospital after being found lying on the floor. Other documents related to fall include Staff L's written statement about finding Resident # 24 lying on the floor in his closet on his left side. The statement did not include the time of the incident. The incident report also did not indicate pertinent information such as time of incident, how Resident # 24 was assisted from fall position, time of transfer to the hospital, and other related assessments/interventions. B. On 4/11/22 at 9:12 AM, the DON verified lack of documentation regarding assessment and/or interventions related to Resident # 24's fall on 8/6/21. The DON reported having tried to search but could not find any. The DON stated, The nurse did not write any notes about the fall. C. On 4/12/22 at 8:09 AM, Staff T Registered Nurse (RN) reported being the nurse when Resident # 24 had a fall on the night of 8/16/21. Staff T said that CNA found Resident # 24 on the floor next to closet. Staff T also said that assessment showed the left leg was more swollen, so the on-call physician was notified and got an order to send Resident # 24 out to the hospital for evaluation, and Resident # 24 was found to have fracture on right leg. When told about the lack of nurse's assessment/intervention notes related to the fall, Staff T commented, It's interesting that there's no documentation. Staff T acknowledged the importance of documentation especially for a fall with major injury. D. On 4/18/22 at 2:34 PM, Staff L CNA reported that at about 4:00 AM on 8/16/21 while doing last rounds, they heard a bang and went to investigate where they found Resident # 24 on the floor to closet in room. Staff L reported that Resident # 24 could not keep still and was moving around from lying position to sitting. Staff L said they called the nurse and another aide and got [Resident # 24] to sit in recliner. Staff L also said that Resident # 24 was complaining of so much pain and added so me [sic] and the other aide helped him to bed. When clarified if Resident # 24 walked from recliner to bed, Staff L stated, we literally put the resident to bed. Staff L further reported that the ambulance arrived an hour later and Staff L said it took a long time for the ambulance to come, it was crazy. Staff L said the ambulance took Resident # 24 to the local hospital at about 5 AM. F. The latest quarterly MDS prior to the fall dated 5/27/21, identified Resident # 24 needed limited assistance and 1-person physical assistance for transfers. In addition, documents and interview revealed a decline in Resident # 24's ADL functioning, as follows: A. The progress notes (admission) indicated that on 8/20/21, Resident # 24 returned to the facility from the hospital per stretcher, and at skilled level of care. The admission notes indicated Resident # 24's ADL needs as noted, is totally dependent on staff for bed mobility, is totally dependent on staff for transfers, totally dependent on staff for dressing needs, extensive assist with meals, is totally dependent on staff for toileting needs, and is totally dependent on staff to complete personal hygiene. B. A significant change MDS dated [DATE], showed Resident # 24's ADL needs as follows: extensive and 2-person physical assistance for transfers; performed no ambulation in room, corridor, and on unit; total dependence and 2-person physical assistance for dressing and personal hygiene, and extensive and 1-person physical assistance for eating. C. On 4/12/22 at 8:09 AM, Staff T reported that Resident # 24 had a rough time for a while, was non-weight bearing for a while and it was hard because the resident does not understand. On 4/11/22 at 9:12 AM, despite directions in residents' care plans for staff to follow fall protocol in the event of falls, the DON reported that the facility does not have written guidelines or protocols regarding management/investigation/follow-up of falls or accidents saying that the facility follows the regs [regulations]. The DON verified the lack of assessments and interventions related to Resident # 24's fall with a major injury. The DON also acknowledged the importance of thorough investigation and to reflect results through accurate documentation. On 4/20/22 at 11:56 PM, the MD acknowledged the importance of complete and accurate information in any documentation and reports. The MD stated expectations that facility staff conduct follow-up investigation and accurate documentation to reflect what actually transpired and the surrounding circumstances of incidents. The MD also stated expectations that facility staff document any assessments and interventions in residents' medical records such as Resident # 24 who sustained a fractured femur. 4. Observation on 4/5/22 at 12:05 PM, revealed an unlocked medication cart parked in the hallway by the wall between the doors to Room # 6 and Room # 8 at the Harbor (memory care unit) while Staff K RN, Staff C CNA, Staff D CNA attended to residents in the dining room. At 12:13 PM, the Rehabilitation Director (RD) walked by and pushed the lock-button. On 4/11/22 at 8:52 AM, the RD verified the medication cart was unlocked during observation on 4/5/22 at 12:05 PM. The RD said she had no idea how long the medication cart had been left unlocked. The RD said, I just happened to walk by and saw that it was unlocked so I pushed the [button] to lock it. Based on clinical record review, observation, family and staff interviews, review of therapy staff education and training, and manufacturer user manual, the facility failed to provide adequate nursing supervision and assistance devices to prevent injury for 1 of 4 residents reviewed for accidents and hazards (Resident #42). The facility also did not consistently formulate interventions to prevent or minimize injury related to falls, and did not conduct a thorough follow-up investigations in order to manage/analyze the cause of the falls for 2 of 4 residents (Resident # 4 and Resident # 24) at risk for falls. As a result, Resident #4 sustained a wrist fracture and Resident #24 a femur fracture. The facility also failed to keep medications locked for 2 of 3 medication and treatment carts. The resident listed on the incident was included in the sample. The facility reported a census of 41 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 admitted to the facility on [DATE]. The MDS documented the resident had diagnoses of atrial fibrillation, osteoporosis, and a fractured left humerus (long bone between the elbow joint and shoulder). The MDS indicated the resident had a fall with a fracture prior to admission. The MDS documented the resident had a brief interview for mental status score of 9 out of 15, indicating moderately impaired cognition. The MDS documented the resident required extensive assistance of one staff for bed mobility, transfers, toilet use and dressing. The MDS documented the resident had impaired range of motion (ROM) to her upper extremity on one side, and had physical therapy (PT) and occupational therapy (OT) services that started on 2/3/22. A physician's history and physical dated 1/31/22 revealed Resident #42 had a deformity and proximal left humeral fracture with mild displacement, complicated by osteoporosis, advanced age, and malnutrition. A diagnostic imaging x-ray report dated 1/31/22 revealed Resident #42 had a left comminuted and mildly displaced fracture of her left humeral neck. The care plan initiated 2/2/22 revealed Resident #42 had a self-care deficit and a fracture to her left humerus due to a recent fall at home. The staff directives included administer medications as ordered, assess for change in condition, provide assistance of one staff for ambulation and transfers, and therapy as indicated. The physician's order sheet dated 3/10/22 revealed PT AROM (active range of motion) to the left shoulder and PT/ OT evaluate and treat as indicated. The progress notes revealed: a. On 3/2/2022 at 10:38 PM, resident on skilled level of care after a recent fall at home which resulted in a left humerus fracture. Resident alert and oriented times three (person, place, time). b. On 3/10/2022 at 7:00 PM, resident returned from a doctor appointment with new orders to discontinue the sling on her arm, PT/OT evaluate and treat, and resident may use walker and have weight bearing as tolerated to her arm. c. On 3/24/2022 at 5:58 PM, resident sat in her room and complained of pain in her left upper arm. Ice pack placed to resident's upper arm, but resident still complained of pain. Nurse reported plan to call clinic and get an x-ray of her left arm since the resident had worked more with her arm in therapy. d. On 3/24/2022 at 6:19 PM, telephone order received