**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and medical provider interviews, and policy review the facility failed to implement root cause analysis interventions for previous falls resulting in a fall with fracture, and to thoroughly assess a resident for possible injury after a fall for 1 of 3 residents reviewed for falls (Resident #1). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. The MDS documented she was dependent on staff for eating, toileting, transferring, and does not walk. The MDS also informed she had diagnoses of compression fracture of the third (3rd) lumbar vertebra (spine in the lower back), anxiety, and depression. Record review of a Progress Note dated 2/12/2025 at 1:59 PM for Resident #1 documented she had an unwitnessed fall in her room at 1:53 PM and was found sitting in her doorway with her back against the door frame facing into the room and during active range of motion she admitted to having some pain to her left leg and was not able to bear weight to her left leg or able to bend at the hip past 90 degrees, and may have a possible fracture to the left hip/leg. Record review of a Progress Note dated 2/12/2025 at 2:10 PM for Resident #1 documented she had an unplanned/emergent discharge at this time as her medical status was unstable and left the facility by ambulance. Record review of Resident #1 Care Plan on 2/25/25 documented the following falls and interventions implemented since her admission to the facility: a. Fall 12/24/24, high low bed, date initiated: 1/1/25 b. Fall 12/26/24, high low bed, date initiated: 1/1/25 c. Fall 1/2/25, education to Certified Nurse Aide (CNA) who left Resident #1 bed in high position that it need to be in lowest position, date initiated: 1/8/25 d. Fall 1/31/25, do not leave out of sight in retreat room, date initiated: 2/14/25 e. Fall 2/10/25, offer toileting on walking rounds, date initiated: 2/10/25 f. Fall 2/12/25, motion sensor in room and/or personal alarm attached when in bed, wheelchair, recliner, date initiated: 2/12/25 Record review of an untitled statement by Staff I, Certified Medication Aide (CMA) dated 2/14/25, documented she found Resident #1 on the floor in her doorway on 2/12/25 and heard and saw Resident #1 yelling my hip, my hip while on the floor then when she came back she saw her sitting in her wheelchair. Record review of a Discharge summary dated [DATE] from a local hospital for Resident #1 documented she was diagnosed with a left hip closed fracture on 2/12/25. During an interview on 2/27/25 at 11:45 AM the Administrator revealed she spoke with Resident #1 after her fall on 2/12/25 and she could not remember if her hip hurt before or after the staff got her up off of the floor, she also informed she would expect staff not to move a resident if complaining of hip pain. During an interview on 2/27/25 at 11:40 PM the Director of Nursing (DON) reveled Resident #1, prior to her fall on 2/12/24, was not able to walk with facility staff, but was able to transfer with one (1) staff member by pivoting to desired locations. She then informed she educated Staff E immediately after Resident #1 fell and informed her residents are not to be moved from the floor if they are complaining of pain or other signs of possible broken bones and to immediately call the ambulance. She then informed the facility is looking at every residents prior falls and current Care Plans to ensure interventions implemented were appropriate and still relevant to meet the residents needs. During an interview with Staff E, Registered Nurse (RN) on 2/27/25 at 12:58 PM revealed she was the nurse that assisted Resident #1 with her fall on 2/12/25 and informed she found her in the doorway of her room on the floor, informed Resident #1 said she was embarrassed and forgot to call for help. Staff E then informed when staff assisted her to stand with three other staff Resident #1 had pain when standing. During an interview on 3/4/25 at 10:05 AM with Resident #1's Primary Care Provider, Staff H, Advanced Registered Nurse Practitioner (ARNP) informed Resident #1 has memory issues at times and at others can be spot on. She informed when Resident #1 fell on 2/12/25 she would expect staff not to move her especially if there were signs of rotation of the hip joint or shortening of the legs and wait for the ambulance to transfer her safely. She informed she also saw Resident #1 today at the facility and she is doing well and making progress in therapy and rarely complains of pain. Record review of Falls Incident/Accident Prevention dated June 2024 lacked documentation the facility will implement root cause analysis related to each fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow a physician order resulting in an emergency room visit for 1 out of 3 residents reviewed for medication administration (Resident #2). The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had a BIMS score of 10 which indicates moderate impairment of cognitive status. The MDS indicated she had hallucinations and verbal aggression directed toward others. The MDS revealed Resident #2 has diagnoses of Anxiety and Depression. On 4/24/24 at 8:49 AM observed Resident #2 sitting in her wheelchair in her room. She responded to the nurse knocking on her door and refused her medications. She wanted them left in the room but the nurse explained she needed to watch her take them. The Director of Nursing came and talked to resident and convinced her to take the medications. Resident #2 Care Plan initiated on 9/20/22 indicated behavior problem (yelling/screaming, swearing, sad/tearful/crying, repetitive movement, repetitive questions, rejection of care, abusive language, agitation, anxious/restless, accusing others, physical aggression, hitting staff) due to not trusting staff or the way staff approach her. The interventions with a revision date of 9/8/23 directed staff to administer medications as ordered. Monitor/document for side effects and effectiveness. Review of the Nurse Progress Note dated 2/15/24 at 2:47 PM revealed anxious behaviors and the nurse contacted Resident #2 nurse practitioner. Noted it appears resident is having a panic/anxiety attack. A one time order for Lorazepam (medication to reduce anxiety) 1 milligram(mg) was given per the nurse practitioner. The Nurse Progress Note dated 2/15/24 at 3:15 PM revealed the one time dose of Lorazepam was administered. The Nurse Progress Note on 2/15/24 at 5:48 PM revealed nurse was called to room due to Resident #2 lowered to the floor. No injuries noted at this time. Vital signs: Blood pressure (BP) 70/43, Pulse (P) 120, Respirations (R) 20, Temperature (T) 97.5 degrees, Oxygen saturation (O2 sat) was 89 percent on room air. Resident assisted to her wheelchair and recheck of her vitals BP 106/62, P 103, R 18 and O2 sat 96% on room air. The Nurse Progress Note on 2/15/24 11:52 PM revealed the nurse called to Resident #2's room due to she was again lowered to the floor. During the assessment she was lethargic, unable to help stand. BP 70/43, P 120, R 20, T 97.5, O2 sat 89% on room air, recheck of the vitals after settled in her wheelchair revealed BP 106/62, P 103, R 18, O2 sat 96% on room air. No injuries noted. The Nurse Progress Note on 2/16/24 at 12:57 AM revealed a condition report was called to the physician on-call and an order was obtained to send Resident #2 to the emergency department. The Emergency Department Provider Note from 2/16/24 at 2:16 AM revealed at 5:48 PM on 2/15/24 her oxygen saturation was 89% on room air and 96% on room air soon thereafter. At 12:10 AM on 2/16/24, her oxygen saturation was 94% on room air. But at around 1:30 AM nursing home staff contacted the physician on call in the emergency department to inform us of hypoxemia again noted in the patient with an O2 sat of 79%. She was placed on low-flow supplemental oxygen, and emergency services notified. Responding medics placed her on 10 Liters non-rebreather mask at the time of transport. According to the review of her nursing home notes, the patient had been increasingly confused and somewhat combative/resistive with staff over at least the preceding day. She is normally well-oriented per staff. However she is now rather confused. According to her review of the notes, she did not know the year and did not know her son's name. This is not typical for her. In addition the patient was accidentally given Seroquel (antipsychotic medication) 12.5 mg earlier in the evening. This is not a medication that is prescribed to the patient. Resident #2 presented to the emergency department in acute hypoxemic respiratory failure with a significant oxygen requirement, requiring 10 Liters (L) by non-rebreather mask, She was acutely confused, possibility due to acute hypoxia. In the hours leading up to her decline and subsequent ER transfer, the patient had been given a benzodiazepine (Lorazepam) ordered by her primary care physician in addition to later being given a dose of Seroquel accidentally by nursing home staff. Chest imaging with plain radiographs and CT demonstrated no evidence of heart failure or pulmonary infectious process which would otherwise explain her hypoxemia. COVID-19, influenza and RSV testing was negative. Evaluation of concern for pulmonary embolism was within normal limits. Final diagnosis acute hypoxemic respiratory failure requires continuous at home supplemental oxygen. Medication administered in error, accidental or unintentional, bilateral lower leg cellulitis. A follow up visit Progress Note dated 2/19/24 from Resident #2 primary care nurse practitioner revealed follow up after ER visit last. Resident is not wearing oxygen, says she does not want to. Resident #2 O2 sat 95% on room air. Resident cognitively intact. Review of the Electronic Medication Administration Record (EMAR) for February 2024 revealed no order for Seroquel for Resident #2. On 4/24/24 8:54 AM the Director of Nursing(DON) stated Staff B, Certified Medication Aide (CMA) was terminated for giving someone a medication there was no prescription for. He admitted to doing it. No other problems with him prior to this incident. It was Resident #2 and she was having other health issues at the same time. She went to the emergency room for shortness of breath and she ended up having cellulitis of the leg. They do track medication errors in the risk management. On 4/25/24 at 8:35 AM Staff A, Registered Nurse (RN) reported on 2/15/24 Staff B, Certified Medication Aide (CMA) made a statement to her about doing something but probably not something he should tell her. He told her he gave another residents Seroquel (antipsychotic medication) to Resident #2. She stated it was about 5:30 PM when he told her and her shift ended at 6:00 PM so she passed it onto the oncoming nurse. On 4/25/24 at 9:46 AM with Staff B, CMA stated Resident #2 had behaviors on 2/15/24 and I went to the nurse in charge and asked if I could give her a Seroquel and she said she sure could use it so I interpreted it as to go ahead and give it. I gave her the Seroquel from another residents medications. He stated before administering a medication you should follow the 7 rights of medication administration and ensure you have the right person, right dose, right route, right medication, right time, right reason and right documentation, needs to be followed. He acknowledged you should never give a medication without a physician order and Resident #2 did not have a physician order on the EMAR for Seroquel. On 4/25/24 at 10:34 AM the Assistant Director of Nursing (ADON) stated on 2/15/24 Resident #2 appeared anxious and agitated, more than usual. A nurse got a one time order and administered Lorazepam (antianxiety medication) around 3 PM. Staff B, CMA came to my office and stated Resident #2 was out of control and needed to be sent out. I informed him she just had a dose of Lorazepam. Around 5:00 PM I was leaving for the day and stopped Staff B to ask how Resident #2 was doing and he stated not great. I visually saw her sleeping and Staff B did not say anything about giving her any medications. Sometime later in the evening the nurse made him call and he told me he did something he should not have and gave Resident #2 someone else medication. The facility provided a policy titled Oral Medication Administration with no date, the purpose is to provide a medication regimen safely and effectively. The procedure directed staff to: 1.) Open the MAR in computer, locate resident, review medications 2.) Obtain any vitals needed for medication monitoring 3.) Perform hand hygiene 4.) Locate residents bubble packs and take them out of the cart 5.) Complete 5 rights of medication administration before popping out medications into the med cup. (do not touch the medications) Review of Documentation of Verbal Warning dated 4/11/24 revealed Staff C, Licensed Practical Nurse (LPN) reported she had changed a residents medication order without obtaining an order first. You must get a doctors order to change the dosage of a medication before adjusting it. No longer tweak medications without obtaining an order first. During an interview on 4/25/24 at 8:54 AM the Director of Nursing stated the verbal warning for Staff C, LPN resulted from her entering Hospice orders for medication before the signed order from the physician was returned. For example when the Hospice nurse is here and we discuss medication changes and then she entered the order before the physician had signed the order. This only occurred one time I am aware of and I told her we can not do it. My expectations for administering medications is they follow the EMAR and they follow the rights of medication administration. Staff should not administer medication without a physician order. On 4/25/24 at 9:07 AM Staff D, Hospice Nurse, stated we collaborate with the facility nurse on appropriate medications and dosages and then contact the physician. The physician needs to agree to the recommendation for it to become an order. On 4/25/24 at 11:05 AM Staff C, LPN stated she did receive a verbal warning about when Hospice comes and they talk about different medications or dosages and then the physician will typically give us the order. I have put the order in the computer before the signed orders come back. The DON educated me to make sure the orders are the same and in case the physician would make a change in the order and also to make sure no mistakes were made writing the order. The facility provided an undated policy titled Receiving Physician Orders which stated Licensed nursing staff may take orders from a physician's office nurse for the attending physician. It is a legal procedure for a nurse to take a phone order from a physician's office nurse per Board of Nursing. The policy failed to address procedure for entering physicians orders into the computer for the medication administration record.