Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out interventions to prevent and/or treat pressure ulcers for 3 of 3 residents reviewed with pressure ulcers (Residents #2, #18, #25). The facility reported a census of 32 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The 2/7/25 MDS assessment tool listed diagnoses for Resident #18 which included diabetes, non-Alzheimer's dementia, and Parkinson's disease (a disease characterized by tremors, stiffness, and slow movements). The MDS stated the resident was at risk for pressure ulcers but had no unhealed pressure ulcers. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 6 out of 15, indicating severely impaired cognition. The facility policy Pressure Injury/Skin Breakdown-Clinical Guidelines, approved 6/2024, stated staff would implement interventions for the prevention and care of skin issues. A 2/18/25 N Adv-Skin Check note stated the resident had an unstageable pressure ulcer, black in color to the right heel which measured 2 centimeters(cm) x 2.2 cm (length x width). A 2/18/25 Care Plan note stated the resident had an unstageable pressure ulcer to the right heel and directed staff to encourage the resident to take his shoes off while in his room. A 2/20/25 Care Conference Note stated the facility discussed getting slippers for the resident when he sat in the chair. A 2/25/25 N Adv-Skin Check note stated the resident had a unstageable pressure ulcer, black in color to the right heel. A 3/4/25 N Adv-Skin Check note stated the resident had an unstageable pressure ulcer to the right heel, black in color. A 3/5/25 N. Adv Skin Check note stated the resident had a right heel ulcer, black in color, which measured 1.5 cm x 2.4 cm. A 3/8/25 N Adv Skin Check note stated the resident had a new blood blister to the left heel. The note did not include measurements of the blister. A 3/11/25 N Adv-Skin Check note stated the resident had a black pressure ulcer on the right heel and a blood blister on the left heel. On 3/17/25 at 3:16 p.m., the resident stated he had wounds on both of his heels. He stated when he was in bed, his heel were directly on the mattress and he did not wear boots or utilize pillows to offload his heels. On 3/18/25 at 8:38 a.m. and 9:13 a.m., the resident laid in bed on his back and his heels laid directly on the mattress. On 3/19/25 at 9:13 a.m. Staff B, Licensed Practical Nurse (LPN) measured a round dry-appearing dark-colored wound to his right inner heel as 3 cm x 2.5 cm. The State Agency (SA) asked to see the left heel and Staff B stated she was not aware he had an area on his left heel. She measured a dark red blister on the resident left heel as 5 cm x 5 cm. Staff E, LPN was present during the observation and asked the resident if he would be willing to wear boots in bed if she provided them and he said he would. The facility lacked physician notification of the resident's left heel blister from the 3/8/25 date of discovery until 3/19/25 and lacked documentation of a treatment carried out on the area from 3/8/25 to 3/19/25. The resident's Care Plan lacked further interventions to treat his right heel pressure ulcer and interventions to prevent the development of new ulcers. The Care Plan lacked guidance for staff regarding ways to reduce pressure on the resident's heels. The facility lacked further documentation of providing the resident slippers from the 2/18/25 note until 3/18/25. On 3/19/25 at 3:42 p.m., Staff B, LPN stated she started completing the facility's skin checks last week and stated she was not aware of Resident #18's left heel wound. She stated there was no order for the left heel as of today and stated she would suggest he placed a pillow underneath him for offloading. 2. The 2/15/25 MDS assessment tool listed diagnoses for resident #2 which included quadriplegia (paralysis from the neck down), encounter for change or removal of a nonsurgical wound dressing, and weakness. The MDS stated the resident required substantial/maximal assistance for turning right and left and stated the resident was at risk of developing pressure ulcers/injuries and had 1- Stage 4 pressure ulcer. The MDS listed the resident's cognitive skills as modified independence (some difficulty in new situations only). A 3/19/24 Care Plan entry stated the resident had a Stage 4 pressure ulcer of the coccyx. A 10/1/24 Care Plan entry stated the resident should not sit up in her wheelchair longer than 2 hours related to wound healing. The Care Plan lacked guidance for staff to assist the resident to turn from side to side. On 3/17/25 at 2:20 p.m., the resident laid in bed on her back and her air mattress was on the setting static. She stated she had a new area on her bottom which the Certified Nursing Assistants (CNAs) discovered. She stated she did not roll from side to side but would be willing to if staff assisted her. A 3/17/25 Health Status Note stated CNA's reported a new open area to the resident's buttocks which measured 0.5 cm x 1.0 cm and the facility informed the provider and applied barrier ointment. On 3/18/25 at 3:38 p.m., Staff C LPN measured a wound on the resident's sacrum as 1.2 cm x 0.9 cm x 3.4 cm which had a red wound bed. The resident also had a red, open area on her right lower buttock approximately the size of a quarter. The area had no dressing affixed to it. Staff C stated he did not have orders for this area yet. The resident's air mattress was set to static. The March 2025 Treatment Administration Record (TAR) lacked documentation of a treatment initiated to the resident's right buttock wound from the day of discovery on 3/17/25 until 3/20/25. The facility lacked documentation that the resident was on a turning and repositioning program. On 3/20/25 at 10:40 a.m., Resident #2's air mattress was set on static. The MDS Coordinator stated it should be on alternating and changed it to the air redistribution setting. On 3/20/25 at 11:03 a.m. Staff A CNA stated Resident #2 was on a turning and repositioning program. She stated she had an alternating mattress and when it was on the repositioning setting, this would take care of her turning and repositioning. She stated she would not want to position her on her side while the mattress was set on the redistribution setting as the resident could fall out of bed. 3. The 2/22/25 MDS assessment tool listed diagnoses for Resident #25 which included paraplegia (paralysis from the waist down), depression, and psychotic disorder. The MDS stated the resident was at risk for developing pressure ulcers and had 2 unstageable pressure ulcers. The MDS listed his BIMS score as 13 out of 15. 9/4/24 Care Plan entries stated the resident had a pressure injury and directed staff to carry out treatments as ordered. The March 2025 TAR listed a 2/14/25 order for Mupirocin External Ointment 2%(a medication which prevented bacterial growth in wounds) to the right and left buttock topically at bedtime for left and right ischial(referring to the lower portion of the hip bone) wounds. A 3/11/25 Medication Administration Note stated the resident's Mupirocin External Ointment was not available and staff waited for pharmacy delivery. A 3/12/25 Medication Administration Note stated the facility was out of the resident's Mupirocin ointment and waited for the pharmacy to deliver. On 3/19/25 at 8:44 a.m., Staff B LPN measured a wound on the left hip as 5 cm x 5 cm and a wound on the right buttock as 4 cm x 4.5 cm. The left hip wound had a brown, pink, and white wound bed and the right buttock had a pink wound bed. Staff B applied Mupirocin ointment to both wounds. On 3/19/25 at 3:53 p.m., the Director of Nursing (DON) stated it would depend on the resident, but they would implement such interventions as position changes, boots, offloading, and gel pads to treat and prevent heel ulcers. He stated if staff discovered a new skin area, they would notify the provider and obtain orders as soon as possible. He stated he did not know about Resident #18's left heel wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interview, the facility failed to ensure timely, consistent, accurate assessments occurred for non-pressure skin wounds including redness to a resident's hand and a wound to a resident's abdomen, and recognition of a condition change for a resident who experienced falls and pain for 4 of 4 residents reviewed for assessment/intervention (Resident #5, Resident #11, Resident #12, Resident #183). This deficient practice resulted in a hospitalization, and the worsening of a fracture. The facility reported a census of 35 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 10/18/24 revealed the resident scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which revealed severely impaired cognition. Review of the resident's Care Plan dated 8/25/17, revised on 6/4/19, revealed the following: I have the potential for skin breakdown r/t (related to) poor hygiene and fragile skin. Continued review of Interventions per the Care Plan revealed, in part, the following interventions: a. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Created Date 8/25/17. b. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (Medical Doctor). Created Date 8/25/17. c. Weekly full body skin assessment. Created Date 12/7/22. The Progress Note dated 1/8/25 at 9:26 PM revealed, Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal .Skin Issues: Skin Issue: #001: New skin Issue. Location: Right Lower Quadrant Midline. Laterality / Orientation: Middle. Additional location information: Chronic lesion where resident picks at wound Issue type: Open lesion. Wound acquired in-house. It is unknown how long the wound has been present .Length (cm) (centimeter): 0.5 Width (cm): 0.5 Depth (cm): 0 Undermining: No. Surrounding tissue: Normal in color. Periwound temperature: Normal. Skin issue education: Treatment of skin issue. Additional skin issue education documentation: Instructed resident to not pick at wound. The Bath/Skin Sheet dated 1/15/25 indicated the resident's abdominal folds were reddened. The Bath/Skin Sheet dated 1/19/25 revealed under the Reddened Areas section of the form the resident's abdominal folds were reddened. The word stomach had been written on the assessment and circled. The following comment had been written on the Bath/Skin Sheet: [NAME] and red spot on stomach side rolls very red. On 1/22/25, review of the resident's N-Adv Skin Check history revealed the most recent assessment completed on 1/8/25. During an observation on 1/29/25 at 10:38 AM, Resident #5 in their room, and the resident's abdomen observed with Staff C, Certified Nursing Assistant (CNA). The resident had a wound open approximately smaller than a dime size to the resident's left lower abdomen, with surrounding redness present. Staff C queried if had known the wound present, and responded she did not, was not sure if the other ladies had noticed it, and acknowledged she had not. Review of a N Adv-Skin Check for Resident #5 dated 1/29/25 at 3:53 PM revealed right lower quadrant midline chronic lesion where resident picks at wound, described as in house acquired open lesion which measured 0.5 centimeter (cm) by 0.5cm by 0 cm. During an interiew on 1/30/25 at approximately 5:00 PM, the Director of Nursing (DON) queried about whether familiar with Resident #5 picking, and responded right here, and indicated the abdomen. When queried if resident normally picked left or right, the DON indicated left. The DON acknowledged in the assessment tab was skin tab supposed to be done every week, and if problem with wounds needed to call the DON in to look at it. When queried if everyone should have a skin check in the [electronic health record (EHR)] weekly, DON explained they are behind. During an interview on 1/30/25 at 6:48 PM, the facility Administrator queried regarding skin assessments, explained last survey had issues, had explained had constantly been asking [DON] if getting done, and response given was yes. 2. Review of the MDS assessment for Resident #12 dated 11/1/24 revealed the resident scored 9 out of 15 on a BIMS which indicated moderately impaired cognition. Per this assessment, the resident was always continent of urine. Review of Resident #12's Care Plan dated 9/6/24 revealed, [Resident #12] has FUNCTIONAL bladder incontinence r/t (related to) Dementia. Review of the intervention dated 9/6/24 revealed, Monitor/document for s/sx (signs/symptoms) UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The Behavior Note dated 11/24/24 at 7:47 AM revealed, The resident started to put herself on the floor as a behavior. Resident came out of her room into the hallway and sat down on the floor and proceeded to lay down in the hallway. Resident is also putting herself on the floor in her room and rolling around on the ground. all these behaviors have been witness from staff as she puts herself on the floor. The next Progress Note documented in Resident #12's EHR was dated 11/24/24 at 6:25 PM. The Health Status Note dated 11/24/24 at 6:25 PM documented by Staff L, Registered Nurse (RN) revealed, Resident put self on floor at 1803 (6:03 PM) and hit her head when she landed on butt and went to her right side. V/S (vital signs) 118/77, O2 (oxygen) 82 RA (room air), P (pulse) 133, R (respirations) 18, T (temp) 97.3. Resident assisted to sitting position and then standing with no injuries noted. Resident taken to room resident found on floor at 1810 (6:10 PM). Resident cool and clammy at this time. BG (blood glucose) was 170. Staff reports 15-20 incidents on day shift of resident sitting her self on floor. Call to [Dr. Name Redacted] and order to send t <sic> ER (Emergency Room) for eval. During an interview on 1/28/25 at 12:02 PM, Staff L explained they had gotten report resident had fallen or put self on the floor multiple times that day, and Staff L thought they said 15 times. Staff L explained resident sent to the ER that night she did believe, and thought did send her (resident). Staff L explained when the resident did so again when Staff L was there, Staff L thought oh my gosh, something else is going on with her (resident). When queried if Resident #12 hit her head on that incident Staff L acknowledged resident did, and further explained she was told (resident) hit her head multiple times that day. Staff L queried if anything had been going on with the resident's urine, and responded off the top of her head she could not remember. On 1/28/25 at 10:09 AM, incident/accident reports and any corresponding investigation for Resident #12 for the last six months requested via email from the facility's Administrator. On 1/28/25 at 4:40 PM, the facility Administrator responded via email the resident had two incident reports for the last six months, noted to to lack documentation for 11/24/24. Review of the ED (Emergency Department) Provider Notes dated 11/24/24 at 6:51 PM revealed, Chief Complaint Patient presents with fall. The History of Present Illness (HPI) section revealed, [Resident #12] is a [age redacted] yo (year old) female presenting from [Facility Name Redacted] with abdominal pain and multiple falls today. She presents with EMS (Emergency Medical Services) who give history. EMS reports the patient has Alzheimer's/dementia and she is unable to give history. EMS reports that patient was endorsing abdominal pain en route but has not had any vomiting. They report that his prior reported to them the patient had multiple falls today, potentially up to 10 different falls. They also reported that the patient seemed to be throwing herself on on the floor. Patient is usually cooperative and follows commands however today she has not been listening to instructions. Review of the Physical Exam section revealed the resident had abdominal tenderness and back pain. Review of the ED Handoff Note dated 11/24/24 at 7:05 PM revealed, in part, [Resident #12] was sent from nursing home after having multiple abrupt sit downs where she sat down very hard onto her buttock. I spoke with [Name Redacted] from the nursing home and provider who witnessed 2 of these events stating she fell back and hit her head after sitting abruptly. No loss of conciousness. She is not redirectable, restless and has been like this all day although it has not been documented. Review of the After Visit Summary from [Hospital Name Redacted] dated 11/24/24 revealed, we are culturing [Resident #12's] urine. She has a very apparent urinary tract infection and was given 2 g (gram) of ceftriazone here in the emergency department. Per the After Visit Summary, the resident had the following reasons for visit listed: fall, initial encounter, complicated UTI, and delirium. Review of Progress Notes for Resident #12 dated 11/24/24 lacked documentation of any urinary symptoms or pain on 11/24/24. The Urinalysis with Microscopy included in the hospital records with collection date 11/24/24 at 8:27 PM revealed the resident's urine was turbid, had trace ketones and blood, had 1+ protein, had 2+ nitrites, 500 leukocyte esterase, greater than 100 white blood cell,6-10 red blood cell, many bacteria, and 1+ hyaline casts. The Infection Note dated 11/24/24 at 9:42 PM revealed, Call report from [Hospital Name Redacted] ER resident update given. Rocephin 2 for UTI .Resident has bad UTI Resident will return on oral ABT (antibiotics) per ER nurse. The Progress Note dated 11/24/24 at 11:00 PM for Date of Service 11/25/24 revealed, Patient had multiple falls this weekend. Was evaluated for back pain. Patient had multiple falls this weekend. Was evaluated at the hospital yesterday and diagnosed with UTI. Was prescribed cephalexin 500mg 4 times a day for 7 days. Patient is still experiencing significant painful urination. During an interview on 1/29/24 at 10:02 AM, Staff C queried if had ever been at facility when resident fell, and responded no, not accidentally. Per Staff C, the resident would put self on the floor sometimes, and would lay elegantly, described as slow motion. When queried if had ever seen resident put herself on the ground and hit their head, Staff C responded no. When queried if it was a pretty controlled movement, Staff C responded yeah, absolutely. During an interview on 1/30/24 at 12:08 PM, Staff Q, Registered Nurse (RN) explained she had been in shift where the resident would say help me, to room, then would throw self to ground. When queried if an incident report would be written up when resident did so, Staff Q responded she did not know, and if fall do risk management. Per Staff Q, did not think there would be incident report because everybody knew. During an interview on 1/30/25 at 4:34 PM, the Director of Nursing (DON) explained resident would tell everybody that going to put self on the floor, if put self on the floor and hit head should be treating it as a fall, and no one ever told her about that. The DON explained if fell and hit head needed to be incident, and should start neuros. When queried if any urinary complaints for resident were passed to the DON, the DON responded no, and per DON standard diagnosis from the hospital was UTI. The DON further explained the problem was never see the culture result back, and needed to see the culture. Regarding a change in clinical presentation, the DON explained she needed documentation number one of what the change was, and if significant enough DON needed to be called and let DON know. When queried if she was being called, the DON responded once in a while, and most of the time called with fall/no injury. 3. The Minimum Data Set (MDS) assessment, dated 10/25/24, revealed Resident #183 had both short term memory and long term memory problem, as well as fluctuating symptoms of inattention, disorganized thinking, and altered level of consciousness. Diagnoses included diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia (schizoaffective disorder). The MDS revealed Resident #183 had 2 or more falls without injury, 2 or more falls with injury (except for major), and 0 falls with major injury during this assessment period. The MDS, dated [DATE], revealed Resident #183 dependent on staff for transfers and unable to ambulate. The MDS indicated during this assessment period Resident #183 had 2 or more falls without injury, had 2 or more falls with injury (except for major), and had 1 fall with major injury. Major injury defined in MDS assessment as bone fractures, joint dislocations, closed head injuries with altered level of consciousness, or subdural hematoma. A review of Progress Notes in the electronic health record revealed: a. On 12/06/24 at 9:12 PM, Resident #183 had an unwitnessed fall in room without apparent injury or indicators of pain. b. On 12/07/24 at 7:36 AM, . Resident #183's right elbow described as swollen and warm/tender to touch. Resident experienced pain when straightening arm. c. On 12/08/24 at 8:51 AM, Resident #183 had an abrasion to the right eyebrow and limited range of motion (ROM) to right upper extremity with bruising and mild swelling to the lateral elbow. d. On 12/09/24 at 2:34 PM, Resident #183 stated she had pain in the right elbow, nurse noted swelling had gone down. At 5:25 PM Resident #183 had fall in room with verbal complaints of pain to right elbow. No documentation of pain medication offered or administered post fall. e. On 12/11/24 at 7:32 AM, Resident #183 . had limited ROM of the right upper and lower extremities. Resident #183 .moans and groans with passive ROM, unable to walk, and had pain with touch to right elbow. Physician was called at 7:43 PM and new orders received to obtain X-Ray of right elbow and right knee. f. On 12/12/24 at 6:45 PM, portable X-Ray results revealed an acute moderately displaced avulsion fracture of the right elbow, physician was notified of results and ordered an Orthopedic consultation. g. On 12/13/24 at 8:35 AM, Resident #183 was sent to the Hospital via ambulance for Orthopedic Consultation at this time, and at 6:15 PM, call from the Hospital received to notify facility of mildly displaced fracture of the right trochanter (hip) found at the Hospital in addition to right elbow fracture. h. On 12/14/24 at 5:02 PM, Resident #183 sustained fall after standing from wheelchair in dining room, no injuries were observed at time of fall. i. On 12/16/24 at 2:44 AM, Resident #183 occasionally cried out in pain when awake, PRN pain medication given .unable to stand and walk without assist and placed back into recliner where comfortable. j. On 12/17/24 at 4:41 AM, Resident #183 .increased pain and yelled out during transfers for cares. Staff utilized gait belt with assist of 3 to stand, pivot transfer, PRN pain medication given. k. On 12/20/24 at 10:19 PM, Resident #183 still moans and groans with position change and transfer, unwilling to bear weight to bilateral lower extremities. l. On 12/21/24 at 9:15 AM, Resident #183 had facial grimacing with position changes, rested for long intervals with eyes closed, and did not eat morning meal. m. On 12/25/24 at 8:18 PM, Resident #183 with diagnosis of fracture right elbow and fracture right hip, had pain with movement. PRN Tramadol and Tylenol given for pain. A review of hospital records from Resident #183's 12/30/24 admission included a History and Physical (H&P). The H&P revealed .[Name redacted] .suffered a ground-level fall at her care facility on the evening of 12/12/24. She presented to the emergency room where x-rays of the right elbow and right hip were obtained as well as CT (computed tomography scan, a non-invasive image) A Hospital Note, dated 12/30/24 indicated Resident #183 seen in Orthopedic Clinic for follow up appointment 2.5 weeks after injury and noted that resident continued to struggle with fairly severe pain in both right hip and right elbow. Resident #183 unable to bear weight of right lower extremity due to severity of pain and is standing with assistance of 2 staff members. Hospital Note indicated that Resident #183 presented to clinic with complications stemming from original injuries, including a wound over olecranon (elbow) which probed deep to bone and progression of greater trochanteric (hip) fracture to an intertrochanteric femur fracture. Hospital Note revealed that facility reported resident had been observed hitting elbow on nearby objects during emotional outbursts, otherwise Resident #183 had no falls or trauma to hip or elbow since seen couple weeks ago, and right elbow splint not removed until today. Hospital Note indicated that information from facility raised concern that these complications were secondary to dementia related agitation and possibly unwitnessed falls at the facility. Resident #183 admitted to hospital from Orthopedic Clinic, in anticipation for surgical intervention for the right elbow and right hip. During an interview on 1/14/25 at 1:00 PM, Certified Medication Assistant (CMA), Staff J, reported that Resident #183 would cry and report pain after fractures found in December. Staff J reported Resident #183 would tell you she was in pain and received PRN Tramadol and Tylenol for pain. During an interview on 1/14/25 at 1:23 PM, Certified Nursing Assistant (CNA), Staff D, reported that following fractures, Resident #183 could not stand and required 2-3 staff assistance to transfer and stated this being a big change for resident used to walk down the hallway to not being able to stand. Staff D recalled that Resident #183 would cry and stated you could tell she had pain and when her pain medications were wearing off. Staff D stated Resident #183 also showed signs of restlessness and anxiety when she was in pain. Staff D informed that she would notify the nurse when signs of pain had been observed. During an interview on 1/14/25 at 1:40 PM, Staff C, CNA, stated she was tasked with transporting and accompanying Resident #183 to the Orthopedic Clinic follow up appointment on 12/30/24. Staff C stated she was informed by Clinic that Resident #183 would be admitted to the Hospital and required surgery, Staff C informed that she notified the Director of Nursing via phone and returned to the facility. During an interview on 1/15/25 at 9:08 AM, Staff DD, Registered Nurse (RN), recalled during a fall follow up assessment, it was noted Resident #183 had limited ROM of right arm and would moan and groan. Resident #183 had bruise around right elbow and Staff DD attempted to use ice to area. Staff DD stated she reported this to the oncoming nurse. She stated when she returned 1 or 2 days later she had learned in report of an additional fall. She stated she noted hand had been more swollen with limited ROM and stated the physician had been notified on a Sunday with order received for X-Ray of right elbow. During an interview on 1/22/25 at 2:00 PM, Director of Nursing (DON) stated that no discharge orders of follow up care instructions had been received from the Hospital Emergency Department (ED) on 12/13/24 following fractures noted to right elbow and right hip. DON stated that the hospital didn't say anything, so she had staff put resident in wheelchair and pivot transfer resident on the good foot. DON stated Resident #183 was having pain and receiving PRN Tramadol, DON confirmed this order had been initiated prior to current injury on 6/27/24. When asked about Resident #183 pain management regimen, DON informed that staff were to keep pain controlled, and provide PRN medication around the clock for resident. DON stated pain medication had been effective because Resident #183 would fall asleep and not cry, noted that if resident had been crying she was hurting. DON revealed the expectation of nurses to call physician if resident pain was rated at 10/10 (severe). During an interview on 1/27/25 at 12:18 PM, a Physician's Assistant (PA-C) from Hospital Orthopedic Clinic, stated discharge instructions for right elbow fracture included non-weight bearing status and Resident #183 sent with slab splint and sling which would stay in place until 1st follow up appointment 12/30/24, and instruction for right hip to weight bear as tolerated and avoid abduction (away from body) movement of hip. PA-C revealed expectation for facility to call Orthopedic Provider if Resident #183 were to have a fall or additional trauma that may cause worsening of injuries and to to call if Resident #183 experienced new, worsening, or unresolved pain. During an interview on 1/30/25 at 2:30 PM, DON again confirmed that no discharge instructions or paperwork had been received from hospital on [DATE] following identification of both right elbow and right hip fracture. DON stated that facility should call hospital if there's no discharge paperwork and that information should then be faxed or emailed to the DON. The DON denied having called hospital for discharge instructions or care orders of right elbow or right hip fractures. DON stated if Resident #183 fell when she had fractures identified, she would expect staff to start assessments and to call Orthopedics to see if resident would need to be seen sooner. DON confirmed documentation lacked notification to Orthopedics for fall on 12/14/24 or for increased pain documented in Progress Notes and Medication Administration Record. 4. The Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Resident #11 utilized a walker for mobility, able to transfer and ambulate in facility independently. Diagnoses included: anemia, hypertension, viral hepatitis, Schizophrenia, Chronic Obstructive Pulmonary Disease (COPD), osteoarthritis of knee, and history of falling. The MDS revealed Resident #11 had 2 or more falls without injury during assessment period. The Care Plan, revised on 1/27/25, identified Resident #11 at moderate risk for falls related to deconditioning and COPD. Care Plan revealed Resident #11 is independent with transfers, toileting, dressing, and personal hygiene and instructed staff to monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. Review of facility provided incident reports revealed Resident #11 had 12 falls between 1/01/25-1/23/25, with 9 of the falls unwitnessed, and no injuries related to falls documented on incident reports. Dates of unwitnessed falls included: 1/03/25 at 7:25 AM, 1/03/25 at 8:00 PM, 1/06/25 at 8:38 PM, 1/08/25 at 8:15 AM, 1/10/25 at 6:10 PM, 1/12/25 at 9:00 AM, 1/13/25 at 12:25 AM, 1/15/25 at 6:00 PM, and 1/22/25 at 9:07 AM. Review of facility provided document, titled Neurological Flow Sheet revealed neurological assessments had been initiated on the following dates/times: 1/04/25 at 11:00 AM, 1/06/25 at 12:20 PM, 1/12/25 at 6:30 PM, and 1/22/25 at 8:30 AM During an observation on 1/11/25 at 11:45 AM, Resident #11 sat in a recliner in her room wearing nightgown and supplemental oxygen set between 2-3 liters, via nasal cannula, resident alert and oriented when approached and reported that oxygen was new for her. Resident #11 denied concerns. During an observation on 1/12/25 at 12:00 PM, Resident #11 sat in a recliner with meal tray on a overbed table, and eating. Oxygen in place at 2 liters via nasal cannula. Review of Resident #11's Progress Notes revealed the following documentation: On 1/03/25, Resident #11 had 3 falls on this day, new order received to check urinalysis. On 1/05/25, Resident #11 received order to start antibiotic (Macrobid) for Urinary Tract Infection (UTI), resident also started on supplemental oxygen at 2 liters via nasal cannula as needed. On 1/08/25 at 9:38 PM, Note revealed that neurological assessments do not need to be restarted at this time per Director of Nursing (DON). On 1/14/25, Resident #11 had witnessed fall, reported dizziness when bending forward, blood pressure noted to be 93/52. On 1/15/25, Resident #11 had unwitnessed fall, reported hitting her head, blood pressure noted to be 138/100 and pulse 110 beats per minute. On 1/23/25, Progress Note revealed multiple falls had been reported by previous shift, indicated approximately 4 falls, review of notes lacked any additional information related to multiple falls occurring on 1/22/25. On 1/23/25 at 12:50 PM, Resident #11 had an unwitnessed fall with blood pressure noted to be 94/71 and at 4:00 PM facility received therapy recommendations for Resident #11 to transfer with assistance of one staff using walker and gait belt at all times. On 1/23/25, Primary Care Provider (PCP) visit note, identified that Resident #11 continued to have falls, no new orders. On 1/24/25 at 9:39 PM, Note informed that Resident #11 is non-compliant with calling for help which leads to multiple falls. Indicated resident already on fall initiated neurological checks and resident falls in between checks due to non-compliance. Note revealed instruction from DON to not start neurological starts over. On 1/26/25 at 2:52 AM, Resident #11 noted to have brown urine with red slimy discharge, strong smell, history of multiple falls in past few days. Physician notified and new order received to check urinalysis, then at 9:05 AM, new order received to start antibiotic (Bactrim) for UTI. On 1/27/25, urinalysis preliminary results received and showed urine positive for blood, protein, and had greater than 100,000 [NAME] Blood Cell (WBC) Colony-Forming Units (CFU) per milliliter of urine, Resident #11 remained afebrile. On 1/27/25 at 9:08 AM, Resident #11 had witnessed fall out of wheelchair in common area near nurses station and at 1:20 PM, Resident sent to Emergency Department via ambulance to be evaluated for blood pressure 92/68, weakness, not being able to hold silverware or feed self, and requiring assist of 2 with gait belt to wheelchair when normally assist of one with gait belt and walker. On 1/27/25 at 12:21 PM, Resident #11 observed in common area by nursing station sat in wheelchair and reaching towards her oxygen concentrator, heard another resident tell Resident #11 she was going to fall out. Resident #11 explained she was trying to move her oxygen concentrator, Staff I, Certified Nursing Assistant (CNA) approached, bringing Resident #11 a sensory ball. At 12:23 PM observed sensory ball on the ground between resident's feet on the floor, staff member picked it up and handed to her, and at 12:24 PM ball again on the floor, Resident #11 reaching to left side, grabbed onto the oxygen tubing and pulled on the tubing, held taught in her hand. At 12:27 PM Resident #11 observed leaning forward attempting to pick ball up from floor again. Hospital Note, dated 1/27/25, revealed Resident #11 presented to Emergency Department (ED) via ambulance after a change in mental status, hypotension, and general weakness. Note informed that resident had started on the antibiotic Bactrim for UTI on 1/26/25 and had urine culture 3 weeks ago which grew E. Coli bacteria that was resistant to Bactrim. Hospital note revealed Resident #11 had Acute Kidney Injury (AKI) with creatinine level (used to monitor kidney function) 2 times her base line, in a setting of likely cystitis (bladder infection). Resident #11 admitted to hospital observation level of care for antibiotics for acute cystitis and monitoring of AKI. Resident #11 given intravenous (IV) antibiotic Ceftriaxone and IV fluids with improvement in blood pressures, and urine culture pending. Hospital Note, dated 1/28/25, revealed Resident #11 had result for positive blood culture of E. Coli and Enterobacterales bacteria. Resident #11 switched from observation to inpatient hospital admission, and bacteremia (bacteria present in blood stream) added to hospital diagnoses/problems list. On 1/28/25 at 12:04 PM, Staff L, Registered Nurse (RN), reported Resident #11 recently had gotten a lot weaker, unable to stand as well and knees would drop down. Staff L recalled that recently staff had to transfer resident as a 2 person assist with gait belt, when previously had been independent to transfer/walk. Staff L stated Resident #11 had been falling a lot lately, with a lot of unwitnessed fall and said when she comes in to work there's no notes on her falls that are verbally passed along in shift report. Staff L stated she received instruction from the Director of Nursing (DON) to not restart neurological assessment, instead continue where you were due to having multiple falls in a day. Staff L stated that on 1/26/25 she requested CNA staff to report appearance of Resident #11's urine because she was falling and had UTI in the past when increased falling occurred. Staff L confirmed urine appeared thick and brown with strong odor and reported to physician with order for to check urinalysis. On 1/29/25 at 9:24 AM, Staff D, Certified Nursing Assistant (CNA), stated Resident #11 had been falling frequently, almost everyday, multiple times a day for at least the past 2 weeks. Staff D stated Resident #11 had more weakness recently and now required a 2 person assist to transfer. Staff D reported Resident #11 would try to get up but couldn't which had been a big adjustment for resident to need staff to help her when previously was independent. Staff D recalled that a day or two before being hospitalized , on 1/27/25, Resident #11 had a change in cognition, when she was normally very with it, was observed grabbing for things that were not present in the air, Staff D stated reporting this information to the nurse. On 1/29/25 at 9:52 AM, Staff C, CNA, reported Resident #11 required assist of 2 for the past week, including use of full body lift. Staff C recalled Resident #11 had been assist of 1 for brief time before current transfer status and previously had been able to transfer and ambulate independently in facility with walker. Staff C recalled fall interventions for Resident #11 included checking on her more frequently and more recently bringing out to nurses station. Staff C stated that Resident #11 may use call light more during the past week as she had been less independent. On 1/29/25 at 1:41 PM, Staff R, Licensed Practical Nurse (LPN), stated neurologic checks should be initiated for each of Resident #11's falls because the falls are not witnessed. Staff R stated fall notification had only included letting the DON know about a fall, because DON informed LPN that physician notification was done by DON. Staff R stated that Resident #11 having multiple falls in a day would be change in condition and physician would need to be called to see if he wanted to get a urinalysis. Staff R confirmed working on 1/22/25 when Resident #11 had multiple (approximately 4 falls during shift) and denied calling physician to notify of falls on this date. On 1/30/25 at 2:30 PM, Director of Nursing (DON) confirmed that Resident #11 had history of UTI's and explained that she typically presented with increased falls when she had a UTI. DON stated she was unaware of Resident #11 requiring assistance of 2 staff to transfer until 1/27/25 at 12:30 PM, just before resident was sent out to the hospital. DON revealed the expectation of nurses to notify the physician, responsible party, and DON, if a resident falls multiple times in a day and informed that the protocol for unwitnessed falls included treating the fall like resident hit their head, by starting neurological exam. DON denied having called the physician on 1/22/25 for multiple falls noted on that day, and did not know if charge nurse on duty had notified resident's physician. DON confirmed that she has informed staff not to restart neurological assessment checks for falls that occur between neurological checks, if resident doesn't hit head, because they would never finish doing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, resident and staff interviews the facility failed to thoroughly investigate falls including identifying root cause analysis, failed to ensure interventions implemented to prevent further falls, failed to ensure gait belt utilized during transfer, failed to care plan and reassess a resident for the ability to safely smoke, and failed to timely update interventions for a resident who had previously exited the facility unaccompanied for 5 of 8 residents reviewed for accidents (Resident #4, Resident #11, Resident #19, Resident #25, Resident #184). Resident #4 sustained eight falls between 6/7/24 and 1/2/25, four of which resulted in injuries including the following: laceration to the scalp requiring 4 staples, laceration to top of head, laceration to right eyebrow requiring 2 sutures, and small hematoma to back of head. The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #4 dated 6/14/24 revealed the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. Per this assessment, the resident had falls since admit, entry, reentry, or prior assessment, two with no injury and one with injury except major. Per this assessment, the resident was independent for chair/bed to chair transfer, and was frequently incontinent of urine. Review of Medical Diagnoses for Resident #4 included Parkinson's, unspecified, dementia with other behavioral disturbance, cognitive communication deficit, unsteadiness on feet, unspecified lack of coordination, personal history of traumatic brain injury, and other seizures. Review of the MDS dated [DATE] assessment for Resident #4 revealed the resident scored 11 out of 15 on a BIMS assessment,which indicated the resident had moderately impaired cognition. Per this assessment, Resident #4 had two or more falls with no injury, and none with injury except major or major injury. Review of Resident #4's Care Plan dated 6/8/22, most recently revised on 6/8/22 revealed the following: Risk for falls a. Fall 1/9/24 after seizure b. Fall 2/22/24, No injury c. 3/31/24 Fall, no injury d. Fall 5/9/24, no injury e. Fall 5/10/24, laceration f. 6/7 Fall, No injury g. 6/29/24 Fall, No injury h. 7/11/24 Fall, laceration i. 7/24/24 Fall, No injury j. 10/15/24 Fall, Laceration to top of head k. 11/10/24 Fall, No injury l. 11/26/24 Fall, Laceration to right eyebrow m. 1/2/25 Fall, small hematoma back of head Review of interventions added to Resident #4's Care Plan from June 2024 to present included the following: a. (Created Date 6/6/24): Fall 5/9/24 intervention, stool riser placed. b. (Created Date 6/6/24, revised 6/11/24): Fall intervention 5/9/24 - PT/OT (Physical Therapy/Occupational Therapy) to eval (evaluation) & Tx (treat). Stool raiser placed over toilet seat. c. (Created Date 6/11/24): Fall 5/10/24 Intervention- Observe resident to be sure he is using wheelchair for mobility. d. (Created Date 7/1/24): Fall 6/29/24 Intervention- Dycem in chair. e. (Created Date 7/12/24): Fall 7/11/24 Sent to ER (emergency room) for staples to back of head laceration. Intervention- Staff to observe when going to room if he needs assist. f. (Created Date 7/29/24, revised 8/21/24): Fall 7/24/24-Intervention- Staff to check on him when he goes to room to be sure he is safe. g. (Created Date 10/21/24): Fall 10/15/24 Injury-laceration to top of head Intervention- Resident reminded to ask for assistance. h. (Created Date 11/22/24): 11/10/24 Fall- Intervention- Staff to be sure bed brakes are on. i. (Created Date 12/10/24): 11/26/24 Fall - Intervention- Staff to make check and change rounds with resident due to more incontinent. j. (Created Date 1/3/25): 1/2/25 Fall Intervention- Staff and resident educated on him to ask for help. The N-Adv Fall Risk Evaluation dated 6/7/24 at 8:39 AM revealed the resident had 3 or more falls in the past 3 months, and the resident's Fall Risk Score was 21.0. Per the evaluation, a score of 10 or higher indicated the resident is at high risk of fall. Another Fall Risk Evaluation dated 6/7/24 at 1:00 PM revealed the resident had 1-2 falls in the past 3 months, and the resident's Fall Risk Score was 11.0. Although the resident's Care Plan revealed the resident fell on 6/7, Resident #4's Progress Notes lacked documentation of a fall. The Incident Report dated 6/7/24 at 10:12 AM revealed, Resident was found sitting on the floor. Resident stated he was trying to straighten his bed and fell out of his chair. The Incident Report dated 6/29/24 at 4:10 PM revealed, Resident was found on the floor of his bedroom. Resident stated he just slipped out of WC (wheelchair). Presdisposing factors revealed incontinent, weakness/fainting, and impaired memory had been selected. The Health Status Note at 6/29/24 at 4:14 PM revealed, Resident is independent with transfers. Resident was found on floor and there was a puddle of water or urine next. to him. Resident stated that he would have gotten up himself. Resident does not have any injuries. Fall was not witnessed. Review of Resident #4's Progress Notes lacked documentation of a fall on 7/11/24, although a fall on 7/11/24 was noted in the resident's Care Plan. The Incident Report for an unwitnessed fall dated 7/11/24 at 10:10 PM revealed, resident rolled up to the nurse's station with blood coming from his head and hands. he was pulled into the nurse's station where his head was cleaned, and vitals were taken and WNL (within normal limits). small bleeding wound noted in the middle of resident's head from what appears to be from a previous occurrence. no other injuries noted. bleeding was stopped and EMS was called along with admin, his [family member, name redacted], and provider was notified. residents' room was cleaned, assessed for pain, and any fall risk .resident said he was trying to go to the bathroom when he fell forward although the wound is on the back of his head. resident says he is not in pain. will continue to monitor. The Immediate Action Taken section documented, in part, Staff to observe when going to room if he needs assist. The ED (Emergency Department) Provider Note dated 7/11/24 revealed, Pleasant [age redacted]-year-old-male presenting with scalp laceration after fall .We thoroughly cleaned this here in the emergency department and this was closed with 4 staples. Review of the Health Status Note dated 7/12/24 at 2:42 PM revealed, Resident denies complaints r/t (related to) fall, does admit to minor pain at site of cranial laceration. Neuro checks WNL (within normal limits), VSS (vital signs stable), appetite poor at noon. The Health Status Note dated 7/13/24 at 5:17PM revealed, No complaints of pain from fall. Staples intact on back of head. The Incident Report dated 7/24/24 at 4:00 AM revealed, Resident's next door neighbor alerted staff that resident was on the floor in the bathroom. Found resident sitting on the floor, fully dressed in puddle of urine. Physical assessment and questioning regarding injury, and he denied any. Assisted to wheelchair, vitals assessed, clothing and bedding changed and he went back to bed. The Immediate Action Taken section documented the following intervention: Staff to check on him when he goes to room to be sure he is safe. Predisposing physiological factors revealed drowsy, incontinent, and gait imbalance were selected. It was noted that the resident's falls on 6/29/24, 7/11/24, and 7/24/24 mentioned need for the bathroom, incontinence, or water/urine on the floor, although an intervention to address toileting was not added to the resident's falls care plan until 12/24. The Incident Report dated 10/15/24 at 6:11 AM revealed, Called to room by CNA. Resident was witnessed falling out of bed and hitting his head and right shoulder on the air conditioner in room. Resident has a laceration to top of had <sic> and an abrasion to left shoulder. Resident stated he was trying to get out of bed to get dressed. The Immediate Action Taken section documented the following intervention: Resident reminded to ask for assistance. The Incident Note dated 10/15/24 at 6:25 AM revealed, in part, Resident's bed was wet and floor was wet. Resident spilled urine from his urinal onto the floor. Room was cleaned and resident assessed. No complaints of pain. No abnormal or out of ordinary deformities .Laceration was cleaned with wound cleanser, applied TAO (triple antibiotic ointment) with Band-Aid. Progress Notes for Resident #4 lacked documentation of a fall on 11/10/24, although it was noted in Resident #4's Care Plan. The Incident Report dated 11/10/24 at 7:05 PM revealed, this nurse was alerted to res's room by cna who stated res was noted on the floor between his wall et bed. res was on his bottom c (with) knees bent et arms around knees with his head resting on his forearms. res denied pain et demonstrated a rom (range of motion) x4, no injuries observed at this time, res was assisted to wc et came out to common area to watch tv et eat a snack. The Immediate Action Taken section revealed, assisted to wc et taken to common area for close monitoring. Intervention-staff to be sure bed brakes are on. The Mental Status section of the Incident Report revealed the resident was oriented to person and confused, and included the following narrative: res stated that he ate supper, but he went to bed prior to eating, res also stated that he didn't have his eve meds, and he did. Review of an Incident Note dated 11/22/24 at 11:00 AM revealed, Resident was found on floor sitting with his buttocks in-between his unlocked wheelchair and his bed. A/O (alert/oriented) per baseline, ROM (range of motion) WNL (within normal limits). no injuries noted. all assessments negative as of this time. resident reports he was self transferring from his bed to his wheelchair and forget to lock in. the the process of doing so, his chair moved and he felt. he refused hitting his head and denies any pain/discomfort. resident had his glasses and shoes on, floor was dry, bed in low position with call light on it. his room was well lit and free of clusters. he was assisted to his wheelchair. resident stable, vitals noted 97.2-84-165/85-18-99% RA (room air). Neurochecks initiated per protocol, family, doctor and hot chart all updated. monitor continues per policy. The eMar-Medication Administration Note dated 11/26/24 at 09:11 AM revealed, in part, At approximately 0852 (8:52 AM), this nurse walked back to the nurse's station from the dining room and witnessed this resident having a seizure. He was sitting in the lounge area, in his wheelchair. Resident's arms and legs were positioned at his sides (arms), and in front of him (legs); BILATERAL upper and lower extremities were rigid and jerking repeatedly. This nurse went to the med cart and retrieved one of the resident's Nayzilam 5mg single-use sprays from the narc box, and administered it into his left nasal passage. Resident's convulsions halted approximately 5 seconds after administration of the spray .Once the convulsions ended, resident was very lethargic. Resident was taken to his room and put in his bed by this nurse, and [Name Redacted], LPN (Licensed Practical Nurse) on shift with me today. The Health Status Note dated 11/26/24 at 3:24 PM revealed, At 1430 (2:30 PM) resident observed having seizure in common area. Assessed for safety and after convulsions ceased resident was assisted back to bed and bed left in low position. After a short while was notified that resident was on the floor in his room. Enteredto find resident on floor and bleeding from laceration on right side of head. EMS (Emergency Medical Services) notified. While awaiting arrival resident was delusional and scooting self around room, was unable to obtain VS (vital signs) or assess d/t (due to) this. The Incident Report dated 11/26/24 at 3:45 PM authored by Staff revealed, Called to resident's room by CMA (Certified Medication Aide) due to resident being observed lying on the floor, with blood coming from an area on his forehead. The Immediate Action section documented the following intervention: Staff to make check and change rounds with resident due to more incontinent. Predisposing Physiological Factors included the following: confused, gait imbalance, impaired memory, recent change in cognition, and other. Review of the Other Info section revealed, Resident has had seizure activity today, 2 witnessed, lasting approximately 1.5 minutes x1, and 2 minutes x1. The Physician Order for Resident #4 dated 5/22/23 revealed, Nayzilam Nasal Solution 5 MG/0.1ML (Midazolam (Anticonvulsant)) 5 mg (milligram) Alternating nostrils as needed for as needed for seizures related to OTHER SEIZURES (G40.89) administer 1 bottle (0.1ml/5mg) into 1 nare, administer 2nd dose (0.1ml/5mg) in opposite nare 10 minutes after 1st dose is given if still seizing or if another seizure occurs. DO NOT give more than 10mg in 24 hours. Do not give more than 10mg q (every) 3 day. Although review of Resident #Progress Notes revealed the following two episodes of seizure activity on 11/26/24, review of the resident's November 2024 Medication Administration Record (MAR) revealed one dose of Nayzilam given on 11/26/24 at 9:09 AM. Review of a Controlled Substances Proof of Use sheet for Nayzilam for the resident revealed two doses received by the facility on 3/11/24, and administration of the medication on the morning of 11/26/24 brought the medication count to zero. However, review of an additional Controlled Medication Utilization Record for Resident #4 revealed 2 doses of Nayzilam were received by the facility on 7/25/24, with none signed off as administered to the resident. Review of History and Physical documentation dated 11/26/24 at 11:39 PM revealed the following: Chief Complaint: Seizure, fall. History of Present Illness: The patient is a [age redacted] year old male .who presented to the emergency room on [Hospital Name Redacted] on 11/26/2024 after having a seizure and falling down. According to the report of nursing staff at [Facility Name Redacted] where he resides, the patient had two seizures on 11/27/2024. Shortly after his second seizure, he was noted to have fallen out of his bed, striking his head resulting in a laceration. During chart review it is noted that he has had multiple visits to the emergency room this year with seizures and falls resulting in head injuries. On arrival to the emergency room, the patient appeared to be postictal (period immediately following seizure activity) and was not responding to questions. Over time he had become more alert, and would intermittently answer questions He received 2 sutures to a laceration above his right eyebrow .Maxillofacial CT (computed tomography) showed mild right frontal scalp and periorbital soft tissue swelling. CT of head and neck were negative for acute process. The N-Adv Post Fall Evaluation dated 11/28/24 at 11:19 AM revealed, Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Resident had a seizure and fell from bed Reason for the fall was evident. Reason for fall: seizure activity Did an injury occur as a result of the fall: Yes. Injury details: Laceration on R (right) eye Did fall result in an ER visit/hospitalization: Yes .Skin: Skin Issue: #001: Skin issue has not been evaluated. Location: Right eye. Laterality / Orientation: Right. Issue type: Laceration. Wound acquired in-house. Wound is new. Incision approximated: Yes. Closure method: Sutures. Painful: No. Length (cm):2 Width (cm): 0.2. The Incident Report dated 1/2/25 at 2:24 PM revealed, Resident had a fall at 1400 (2:00 PM). Resident c/o (complained of) hitting head. Resident has small hematoma to middle of head .I was trying to get up and go to the bathroom. The Immediate Action Taken section revealed, Staff and resident educated on him to ask for help. Predisposing physiological factors revealed incontinent had been selected. The Health Status Note dated 1/2/25 at 2:33 PM revealed, Resident had a fall at 1400 (2:00 PM) in his room attempting to self transfer to the bathroom. Resident c/o (complained of) hitting head. Resident has a small hematoma to the middle of his head with some tenderness to touch. Able to move upper and lower extremities. VS (vital signs) are stable at this time. The Incident Note dated 1/16/25 at 4:20 PM revealed, This nurse was told that resident was on the floor. Upon arriving, resident was sitting on the floor behind the recliner in the living room. Resident stated that he was trying to walk to his room. He was assessed and vitals obtained. No injuries noted andhe denies any pain of discomfort. Resident was also explained to that if he wants to go to his room he is to use the wheelchair and not to walk unassisted. Will continue to monitor. On 1/23/25 at approximately 4:08 PM and on 1/28/25 at 11:40 AM, Resident #4 observed in their wheelchair in the dining room. On 1/29/25 at 9:25 AM, Staff D, Certified Nursing Assistant (CNA) queried as to how the resident transferred, and responded 1 assist with a walker as long as Staff D worked at the facility, clarified as 90 days. When queried if Staff D had been at the facility when the resident had fallen, Staff D responded one time was sitting on bottom on the unit, with wheelchair by the fireplace and resident over by the beauty shop. Staff D explained they were surprised no one saw resident walk that far. On 1/29/25 at 10:04 AM, Staff C, CNA queried how the resident transferred, and responded stand pivot. When queried how long had been that way, Staff C responded a month max, and further explained the resident used to be fairly independent, had a fall, and Staff C felt seeing the resident everyday did not think resident been the same since. When queried in what ways, Staff C responded a lot more contused, agitated very fast. When queried if Staff C was at the facility when the resident fell at that time, Staff C responded they were not. On 1/29/25 at 1:19 PM, Staff R, Licensed Practical Nurse (LPN) queried if had been at facility when Resident #4 had fallen, and responded no. When queried about the incident report she authored for the resident dated 1/2/24, Staff R explained resident trying to get out of chair, and chair went from underneath him, and ended up with a bruise to middle of head. When queried if resident transferred self, Staff R responded she did not think resident supposed to. Per Staff R, the resident was a check and change now, further explained she thought the resident wet themselves, was not aware fully wet, and they took him. On 1/30/25 at 4:43 PM, the facility's Director of Nursing (DON) explained Resident #4 was getting more confused, and had caught him standing in the dining room area, and caught him trying to walk from wheelchair to another area. The DON explained how resident's feet positioned not safe, and when the resident went to sit down on the toilet he basically thumped down, and he broke a couple of the stools that way. Per the DON, a commode put over top of it to see if it worked, and that had worked. The DON further explained the resident continued to have the falls, and per DON did not know if the resident was having fall because had a seizure or not. The DON explained after a seizure the resident slept, and got very sleepy. The DON explained she did not think he was, but there was that possibility. Per the DON, the resident generally had grand mal seizures and generally after had one he slept. When queried as to what staff should do if the resident seized and was not given Nazilym, the DON responded to get the resident away so everyone not seeing him, not able to put in bed if seizing, watch him, wait till the seizure goes,and if no longer seizing hoyer off the floor, and to bed to rest. The DON explained the resident was generally out one to two hours after seizures. Per the DON, the Nazyilam worked, and you could do the nasal spray and within 5 seconds the resident was done seizing. The DON explained the following about the falls process: DON would ask what happened, know exact reason what happened, and DON needed to figure out what to do for an intervention. The DON would enter into the incident report, and it would go into the care plan too. The DON explained would do a study of the root cause, and a lot of times it was unknown. Per the DON, Resident #4's happened all over the place, the resident had been more incontinent the last six months, and were finally getting resident to wear briefs. The DON explained she told staff can't just do him once a day, need to see if go down to his room to change, and have another person try. When queried if root cause was documented, the DON responded no. When queried if the resident could unlock his bed himself, the DON responded she did not think he would be able to do that. When queried about educating the resident, as noted in his interventions, the DON explained you could not educate Resident #4. When queried if the resident would be able to receive education during the last six months, the DON responded no, and clarified the resident doesn't understand if explain to him. The DON explained she did not think it was so much the seizures as resident's balance getting worse and worse, explained the resident used to zip up and down the hall with the walker, and after falls said need to go to wheelchair. Per the DON, the resident would go up and down the hall in their wheelchair as fast as could go, and was not doing that anymore. Per the DON, the resident was slowing down. On 1/30/25 at 6:57 PM, the Administrator explained the following about root cause analysis: The facility talked through it, and didn't do formal root cause analysis. The Administrator believed the DON did one with incident report. 2. Review of the MDS assessment for Resident #19 dated 11/29/24 revealed the resident scored 5 out of 15 on a BIMS assessment, which indicated severely impaired cognition. Review of Resident #19's Care Plan dated 9/8/24 revealed, I requires assistance with ADL's (activities of daily living r/t (related to) Dementia. The intervention dated 9/8/24, revised on 12/6/24, revealed the following: TRANSFER: I need assistance by staff to move between surfaces as necessary. Sit to stand t <sic> be used when unable to transfer 2 assist. Observation on 1/27/25 at 12:28 PM revealed the following: Resident #19 present in the common area by nurses station, and resident in wheelchair. Staff I, CNA and Staff C, CNA attempted to get resident up without the use of a gait belt. The resident's legs were not straight, and the resident was asked if he wanted to sit back down. At 12:29 PM, Staff C got a gait belt, and Staff I and Staff C applied the gait belt to the resident. Next, Staff I and Staff C assisted the resident back up using the gait belt, and Resident assisted up to their walker. Resident #19 still not standing straight up, and Staff J, CMA assisted the other staff, and held the resident's gait belt from a position behind Resident #19. On 1/29/25 at 9:25 AM, Staff D, CNA queried about transfers for Resident #19, explained did stand pivot on him, as well as night shift stand lift. Per Staff D, in the mornings the resident stood well. When queried if gait belt put on if resident moving from wheelchair to walker, Staff D responded could do so, and won't hurt. On 1/29/24 at 10:06 AM, Staff C, CNA explained could usually get the resident to stand with a walker, and arm and arm him, and would do a lot of the work by self. Staff C explained the other day they were not sure what that was about, and further explained was never that hard, and no clue what to do. When queried if the resident normally had a gait belt on, Staff C responded sometimes, and further explained it was usually not that difficult that had to have the gait belt. Per Staff C, the gait belt not as helpful as the stand lift. When queried if the resident normally stood pretty good, Staff C responded, yeah. On 1/29/25 at 4:00 PM, Staff K, CNA queried about transfers for Resident #19 from wheelchair to walker, responded should be 2 (assist), and when queried if would use a gait belt, Staff K responded, definitely. When queried why so, Staff K responded the resident was a pretty big guy, and it could be difficult to get resident up from a sitting situation. Staff K explained they would generally prefer to have another CNA be with them any time taking care of him (Resident #19), explained he (Resident #19) was a pretty big guy, and depending on mood could have behaviors. On 1/30/25 at 4:55 PM, the DON explained if staff getting resident up from wheelchair, should use the stand lift. Per the DON, if trying to transfer, even two trying to do gait belt was not safe. When queried if staff did 2 person transfer if a gait belt should be used for him, the DON responded yeah. 5. The MDS assessment dated [DATE] revealed Resident #25 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS indicated resident dependent with roll left and right; chair/bed to chair transfer; and used wheelchair. The MDS indicated the resident impaired in both upper and lower extremities. The MDS list of diagnoses included: traumatic spinal cord dysfunction; paraplegia; and polyneuropathy (nerve damage in multiple locations), unspecified. The Care Plan did not include a Focus area to address smoking. A review of the N Adv- Smoking and Safety assessment dated [DATE] at 12:47 PM revealed the following: a. following product resident used: tobacco b. does the resident display any of the following? 1. poor vision or blindness 2. limited or no ROM (Range of Motion) in arms or hands 3. follows the facility's policy on location and time of smoking The N Adv- Smoking and Safety assessment dated [DATE] at 3:59 PM revealed the following: a. following product resident used: tobacco b. does the resident display any of the following: 1. balance problems while sitting or standing 2. limited or no ROM in arms or hands 3. drops ashes on self 4. Smoking Safety Notes: Having low blood pressure and passing out. Refusing to take midodrine. having spasms that put him at risk to fall out of w/c. May not smoke at this time A review of Physician Orders revealed the following: a. Start date 10/30/24 and end date 1/16/25- 1. no smoking 2. bedrest with turns q (every) 2 hours from back to left side only 3. meals in bed c (with) HOB (head of bed) raised for meals only, HOB <30 at all other times every shift for wound healing b. Start dated 1/16/25 and end date 1/21/25- 1. May smoke 2 cigarettes a day 2. bedrest with turns q2 hours from back to left side only 3. b. meals in bed c HOB raised for meals only, HOB <30 at all other times every shift for wound healing c. Start date 1/21/25: 1. No smoking 2. bedrest with turns q2 hours from right side to back to left side only 3. meals in bed c HOB raised for meals only, HOB <30 at all other times every shift for wound healing The Behavior Note dated 1/14/25 at 10:08 AM noted to be a late entry, revealed resident upset and states he wants to smoke. Educated resident on the smoking policy and the low temperatures outside. Resident states he is going to sign himself out and go no matter what. Resident is his own RP (representative) and with a BIMS of 15. Educated resident on health risks for frostbite and cold weather injury, resident states he understands and demands to go anyway. Resident signed self out and left the facility. This administrator followed resident outside to monitor resident for safety. When resident returned to the facility in his power w/c (wheelchair) he ran into the shelf/wall 2 times being unable to maneuver through the door and around a corner, this administrator took over w/c control and guided him out of the tight space. Resident states this was because he had sunglasses on and could not see. Educated resident on safety with use of power w/c within facility and if he has another incident her will not e able to use power w/c until PT (Physical Therapy) assessed for safety. During an interview on 1/22/25 at 2:13 PM, Resident #25 wheeled up in his electric wheelchair and told he couldn't go out and smoke and they did a wheelchair assessment on him and physical therapy said he didn't pass. Resident #25 said he told them he would sign himself out to go smoke and the DON came up to him and said she would get AMA (Against medical advice) papers and he was like what. Resident #25 stated they were bullying him. He stated he spoke to the doctor and they told him he shouldn't smoke and if he needed to smoke, he needed to smoke the least amount possible so his wounds could heal. The Health Status Note dated 1/22/25 at 4:02 PM, revealed resident went against doctors' orders for no smoking and went outside to smoke anyways. The Health Status Note dated 1/26/25 at 6:30 PM, the per Doctor's orders, resident is to have two cigarettes per day. Resident went out at 1600 to smoke. He had 2 cigarettes. Resident is upset that CNAs (Certified Nurse Aide) did not come put him to bed when he wanted to, so he wheeled himself back up to the nurse's station and insisted that he is going to go outside and smoke. Resident reeducated on the doctor's orders, and he says, That's not a doctor's f**king order. I made that sh*t up. Resident told we would call DON (Director of Nursing) per policy to see if it was an exception, resident stated, F**k [name redacted]. She is not my God. Resident explained to that he is not the only resident, and we were getting to him. Residents insist on a cigarette. Resident is cursing about his electric chair. Resident refusing to go to bed after multiple attempts and just sitting by the door until the smokers go out. Resident wanted the sign out book and said, Now, that I signed myself out, I can do what I want. Last time I checked, adults can do what the hell they want. DON called and told her what is going on,and stated, Let resident go out at 7 with the smokers. Resident is in the hallway with the smokers at this time and seen another resident and said, that's that f**king lady that rolled over my foot. You think they did anything about it. During an interview on 1/29/25 at 11:28 AM, the DON queried on Resident #25 smoking and she stated the doctor didn't want him to smoke because it affected his wound healing. The DON stated he wasn't safe to smoke, he dropped his cigarettes, but he threw such fits we let him smoke. The DON stated they went several months without smoking and then all of a sudden everything blew up. The DON asked about smoking assessments and she stated they were done quarterly. The DON informed the last assessment completed in October indicated he couldn't smoke, but he was, should another one been done and she stated her nurse didn't do one and yes, one should of been completed, but he would of failed again. The DON said he said he had a right to smoke. The DON asked if he could sign himself out to smoke and she stated he wants to sign himself out to smoke and she told the Administrator he can't do that because it wasn't safe and she told the Administrator if he wanted to smoke he was going to smoke with the other residents at the designated smoking times. The DON asked if smoking needed care planned and she stated yes, she forgot to do it. The Facility Safe Smoking Standard Policy dated 9/24/24 revealed the following: a. Safe smoking interventions will be reviewed at least quarterly on all residents who desire to smoke. An assessment will be completed if a change in condition warrants. b. The following steps will be used to evaluate a resident's risk while smoking: a. An initial Safe Smoking Evaluation will be completed on admission. The care plan will be developed and revised as indicated. b. All residents that smoke will be required to sign a Smoking Practice Agreement that they will not attempt to obtain or exchange smoking ma[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS Assessment for Resident #4 dated 12/13/24 revealed the resident scored 11 out of 15 on a BIMS assessment, which indicated moderately impaired cognition. The Care Plan dated 5/25/23 revealed, [Resident #4] has a seizure disorder r/t (related to) Head injury. The Intervention dated 5/25/23 revealed, Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. The Physician Order for Resident #4 dated 5/22/23 revealed, Nayzilam Nasal Solution 5 MG/0.1ML (Midazolam (Anticonvulsant)) 5 mg (milligram) Alternating nostrils as needed for as needed for seizures related to OTHER SEIZURES (G40.89) administer 1 bottle (0.1ml/5mg) into 1 nare (nostril), administer 2nd dose (0.1ml/5mg) in opposite nare 10 minutes after 1st dose is given if still seizing or if another seizure occurs. DO NOT give more than 10mg in 24 hours. Do not give more than 10mg q (every) 3 day. The eMar-Medication Administration Note dated 11/26/24 at 09:11 AM revealed, in part, At approximately 0852 (8:52 AM), this nurse walked back to the nurse's station from the dining room and witnessed this resident having a seizure. He was sitting in the lounge area, in his wheelchair. Resident's arms and legs were positioned at his sides (arms), and in front of him (legs); BILATERAL upper and lower extremities were rigid and jerking repeatedly. This nurse went to the med cart and retrieved one of the resident's Nayzilam 5mg single-use sprays from the narc box, and administered it into his left nasal passage. Resident's convulsions halted approximately 5 seconds after administration of the spray .Once the convulsions ended, resident was very lethargic. Resident was taken to his room and put in his bed by this nurse, and [Name Redacted], LPN (Licensed Practical Nurse) on shift with me today. The Health Status Note dated 11/26/24 at 3:24 PM revealed, At 1430 (2:30 PM) resident observed having seizure in common area. Assessed for safety and after convulsions ceased resident was assisted back to bed and bed left in low position. After a short while was notified that resident was on the floor in his room. Entered to find resident on floor and bleeding from laceration on right side of head. EMS (Emergency Medical Services) notified. While awaiting arrival resident was delusional and scooting self around room, was unable to obtain VS (vital signs) or assess d/t (due to) this. The Incident Report dated 11/26/24 at 3:45 PM revealed, in part, Resident has had seizure activity today, 2 witnessed, lasting approximately 1.5 minutes x1, and 2 minutes x1. Although review of Resident #4's Progress Notes revealed two episodes of seizure activity on 11/26/24, review of the resident's November 2024 Medication Administration Record (MAR) revealed one dose of Nayzilam given on 11/26/24 at 9:09 AM. Review of a Controlled Substances Substances Proof of Use for Nayzilam for the resident revealed two doses received by the facility on 3/11/24, and administration of the medication on the morning of 11/26/24 brought the medication count to zero. However, review of an additional Controlled Medication Utilization Record for Resident #4 revealed 2 doses of Nayzilam were received by the facility on 7/25/24, with none signed off as administered to the resident. On 1/23/25 at approximately 4:08 PM and on 1/28/25 at 11:40 AM, Resident #4 observed in their wheelchair in the dining room. On 1/29/25 during an observation conducted with the facility's DON, a Nayzilam box observed in the medication cart. The DON described the effect of the medication as instantaneous. On 1/30/25 at 1:16 PM, Staff AA, Pharmacy Technician explained resident's Nayzilam had last been sent out on 7/25/24, the pharmacy filled it, and explained the package size was two. 3. The MDS assessment dated [DATE] revealed Resident #31 scored a 12 out of 15 on the BIMS, which indicated moderately impaired cognition. The MDS list of diagnoses included: seizure disorder or epilepsy, intermittent explosive disorder, schizoaffective disorder. The MDS indicated the resident took antipsychotics, antidepressants, and anticonvulsants. The Care Plan revealed a focus area dated 12/25/24 for a seizure disorder. The interventions dated 12/25/24 revealed give seizure medication as ordered by doctor, and monitor/document side effects and effectiveness. A review of Physician Orders on 12/6/24 revealed Xcopri oral tablet 50 mg- give 1 tablet by mouth in the evening related to .SYMPTOMATIC EPILEPSY AND EPILEPTIC SYNDROMES .; Xcopri oral tablet 100 mg- give 1 tablet by mouth in the evening; Xcopri oral tablet 200 mg- give 1 tablet by mouth in the evening; and Rufinamide oral tablet 400 mg- give 3.5 tablet by mouth two times a day related to . SYMPTOMATIC EPILEPSY AND EPILEPTIC . A review of the December 2024 MAR revealed rufinamide 400 mg tablet- 3.5 tablet by mouth two times a day- marked with a 9 on 12/21/24 morning and evening dose. A review of the January 2025 MAR revealed the following information: a. Xcopri 200 mg give 1 tablet by mouth in the evening- marked with a 9 on 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25. b. Xcopri 50 mg give 1 tablet by mouth in the evening- marked with a 9 on 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25. c. Xcopri 100 mg give 1 tablet by mouth in the evening- marked with a 9 on 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25. Per the MAR Chart Codes, a 9 used to indicate Other/See Nurse's Notes. A eMar- Medication Administration Note dated 1/8/25 at 6:37 PM, revealed Xcopri Oral Tablet 100 MG- Give 1 tablet by mouth in the evening related to localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus- Waiting to receive from pharmacy During an interview on 1/14/25 at 3:30 PM, Staff A, Licensed Practical Nurse (LPN) she stated sometimes there is an issue getting medications from the pharmacy and if she had issues, she called the pharmacy. Staff A asked if the CMA let her know if they don't have a medication and she stated yes, Resident #31 xcopri, and she didn't believe it had come in yet. Staff A asked if she knew why the medication had not came from the pharmacy yet and she stated no, the facility spoke to them with the DON been the last one to contact them. During an interview on 1/15/25 at 9:00 AM, Staff DD, Registered Nurse (RN) queried about Resident #13 being out of any of his medications and she stated not that she noted or been reported to her. She stated the pharmacy sent some of his seizure medications but some didn't come in. During an interview on 1/15/25 at 2:35 PM, the DON queried if they had any issues with pharmacy sending Resident #31 xcopri and she stated the pharmacy sent what we had in the computer. The DON stated it was a high cost medication and she had to sign for the next 14 days. The DON informed the medication had not been administered since 1/7 and stated she knew the medication was here and she would go and look for the pills and no one said anything to her about Resident #31 medication not being sent from pharmacy. The DON asked if she had any concerns with the resident not receiving his seizure medication and she stated yes, he could have a seizure. The DON stated the staff were not good at telling her when they don't have medication and she told them to let her know and she would contact the pharmacy and get it fixed immediately. During an interview on 1/15/25 at 3:37 PM, the DON spoke of the rufinamide not given and she stated it was refilled on 1/3 and they received it 2 days later. The DON informed the rufinamide not given on 12/21/24 and she stated maybe they ran out, but then she stated but it was given the next day and she didn't know what happened. The DON stated the xcopri refilled on 1/1/25 but didn't get refilled because the pharmacy stated it was discontinued, but the electronic health record doesn't show it discontinued. The DON stated the nurses called them [pharmacy] several times and they were told to tell me and she would call pharmacy. The DON stated the order put in on 12/6/24 and never changed. The DON confirmed Resident #31 would receive his medication tonight. During an interview on 1/28/25 at 12:48 PM, Staff L, RN queried on Resident #31 seizure medications and she stated she told day shift to call the pharmacy because when called pharmacy they told to call back in the morning because they didn't refill medication at night unless an emergent situation. Staff L stated they were told the medication was discontinued and we needed a copy of the order. Staff L stated Resident #31 had been out of his medication for a while and they told the DON. During an interview on 1/28/25 at 3:15 PM, the Pharmacy Technician stated the xcopri was a controlled medication and wondered if we [pharmacy] didn't have a script so the pharmacy didn't fill it. The Technician stated they had a script on 12/6 and sent 210 tablets with the resident taking 7 tablets a day, they would be out in 30 days. The Technician stated they [pharmacy] received a new script on 1/14 and they filled it. Staff AA stated they didn't have a script from 1/6/25 to 1/14/25 for the medication. During an interview on 1/28/25 at 3:26 PM, the Pharmacist queried if she could see if the facility sent refill requests for the xcopri and she stated she couldn't answer that because there were lots of ways to request. She stated she vaguely remembered talking to a nurse and they attempted to refill it but the medication was discontinued at that time and didn't see any requests until they filled it again. The Pharmacist stated when talking to the nurse she learned he went to the hospital and the computer system communicated discontinued messages whether controlled or not controlled medication and then when they come back the system will restart the medication unless they are a controlled medication and we would need a new script for them. She stated when they received the new script for the xcopri they sent it out the next day. During an interview on 1/29/25 at 11:07 AM, the DON asked what should have happened concerning Resident #31 xcopri and she stated the staff should have notified me on the first day he didn't have medications. She stated the medication was controlled and they still had a script for it, but said it was discontinued. The DON stated the staff were supposed to order the medications when they went into the blue section of the card so they didn't run out of the medication. A review of the facility policy, dated 10/1024 titled Pharmacy Services Overview revealed a Policy Statement which declared the facility shall accurately and safely provide or obtain pharmacy services, including provision of routine and emergency medications and biological's, and the services of a licensed Pharmacist. A review of the facility policy, dated 10/1024, titled Administering Medications revealed a Policy statement which declared Medications shall be administered in a safe and timely manner, and as prescribed. Guidelines #2. The Director of Nursing Services shall supervise and direct all nursing personnel who administer medications and/or have related functions. Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to ensure anti-seizure, anti-depressant/anti-anxiety medications available for administration as prescribed for 3 of 3 residents (Resident #4, Resident #31, and Resident #184) reviewed for medication errors. The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 1/07/25, revealed Resident #184 admitted on [DATE]. A Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicated intact cognition. No behavioral symptoms recorded on MDS. The MDS listed diagnoses included: post-traumatic stress disorder, moderate intellectual disability, and insomnia. The MDS listed Resident #184 took medication in the following drug classes: antianxiety and antidepressant. The Care Plan, initiated 1/10/25, revealed Resident #184 utilized venlafaxine an antidepressant related to a diagnosis of depression with the goal to be free from discomfort of adverse reactions related to antidepressant therapy. Interventions included monitoring and documenting effectiveness of medication A review of Resident #184 January 2025 Medication Administration Record (MAR), revealed an order for Venlafaxine HCI ER Oral Capsule Extended Release 24 hour. Give 1 capsule by mouth one time a day for Anxiety Disorder, Unspecified. Start date 1/1/25, D/C (discontinue) Date 1/8/25. The MAR documented a 9 on 1/01/25, 1/02/25, 1/03/25, 1/04/25, 1/05/25, and 1/06/25. Per the Chart Codes on the MAR a 9 is used for Other/See Nurse Notes. A review of e-Mar- Medication Administration Notes revealed: a. On 1/1/25 lack of a note to indicate the reason a 9 charted for the AM (morning) dose of venlafaxine. b. On 1/2/25 at 7:35 AM, a note documented Venlafaxine HCI ER Oral Capsule Extended Release Not on Hand. c. On 1/3/25 lack of a note to indicate the reason a 9 charted for the AM dose of venlafaxine. d. On 1/4/25 at 8:26 AM, a note documented Venlafaxine HCI ER Oral Capsule Extended Release Not on Hand. e. On 1/5/25 lack of a note to indicate the reason a 9 charted for the AM dose of venlafaxine. f. On 1/6/25 lack of a note to indicate the reason a 9 charted for the AM dose of venlafaxine. A Health Status Note entered on 1/6/25 at 12:45 PM, revealed Resident with increased anxiety. Crying, saying she feels as if she can't breathe, and she thinks she might have pneumonia. On her phone with her daughter telling her [daughter] she doesn't know what's going on with her. Assessment completed on her. Lungs sounds clear .[doctor name redacted] notified and gave one-time order for Lorazepam 0.5 mg . #184 had increased anxiety, crying, and saying she felt as if she can't breathe, physician notified and one time order given for Lorazepam 0.5 mg (antianxiety medication). The January 2025 revealed an order for Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour. Give 75 mg by mouth one time a day related to Anxiety Disorder, unspecified. Start Date 1/7/25. Documentation on the MAR revealed the medication started on the AM of 1/7/25 and continued as ordered through AM on 1/12/25. During an interview on 1/30/25 at 10:00 AM, a Pharmacy Technician from the consulting pharmacy stated the stated the pharmacy received a script for venlafaxine on 1/06/25 at 11:30 AM and sent 6 capsules the same day. The pharmacy delivered 30 capsules of venlafaxine on 1/12/25. Pharmacy Technician stated the pharmacy did not receive communication from facility about this medication until 1/06/25. During an interview on 1/29/25 at 3:49 PM, Staff K, Certified Nursing Assistant (CNA), stated staff knew Resident #184 was having anxiety symptoms when seen [her] rocking in recliner and would notify the nurse when episodes of anxiety had been observed. During an interview on 1/29/25 at 1:06 PM, Staff X, Certified Medication Assistant (CMA) stated that when a 9 was documented in MAR, this would indicate the medication had not been available or could not find the medication and the nurse on duty would need to be notified that the medication had not been given. During an interview on 1/30/25 at 3:30 PM, the Director of Nursing (DON) confirmed a code 9 on the MAR would inform staff to see a Nurse Note and would be selected if the medication was not available. DON claimed Resident #184 had been unable to get venlafaxine due to payment issues and was unaware original order for this medication lacked dosage. DON stated Resident #184 would rock pretty hard in chair when anxious and said this would happen pretty often when she first got to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to prevent a pressure ulcer from increasing in size and depth for one of one residents reviewed (Resident #2). The facility reported a census of 29 residents. Findings include: The Minimum Data Set, dated [DATE] identified Resident #2 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Stage IV Pressure Ulcer to the Sacral Region, Neurogenic Bladder and Quadriplegia (paralysis of all 4 limbs). The MDS also identified Resident #2 as dependent on staff for toileting, dressing, lower body dressing, transfers, and showers. The Clinical admission assessment dated [DATE] had documentation of the following: Resident #2 had a stage IV pressure ulcer to the gluteal area which had the following measurements: Length = 1 cm (centimeters) Width = 0.5 cm D= none documented No odor, tunneling or undermining or drainage. Peri wound normal. On 3/19/24, the Care Plan identified Resident #2 with the problem of a stage 4 pressure ulcer of the coccyx related to immobility and directed staff to: a. Document location of wound, amt of drainage, peri-wound area, pain, edema, and circumference measurements. b. Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. A review of the facility Skin Only Evaluations had documentation on the following dates: 4/5/24 L (length) =1.3 cm, W (Width)=1 cm, D (Depth)=3 cm No wound odor, tunneling, undermining or drainage. Skin tissue painful. Wound bed with granulation. Wound exudate serous. Dressing saturation heavy >75% 4/13/24 L=2 cm, W= 2 cm, D=2.7 cm No wound odor, tunneling, undermining or drainage. Skin tissue painful. Wound bed with granulation. Wound exudate serosanguinous. Dressing saturation moderate 4/18/24 L=2 cm, W=1 cm, D= 2.7 cm No wound odor, tunneling, undermining or drainage. Skin tissue painful. Wound bed with granulation. Wound exudate serosanguinous. Dressing saturation moderate 5/7/24 L= 2 cm, W= 2 cm D= 3.5 cm No wound odor, tunneling, undermining or drainage. Skin tissue painful. Wound bed with granulation. No wound exudate. A review of the Nurse Practitioner Note dated 5/10/24 at 4:16 PM revealed the following: Wound Assessment: The opening is circular measuring just under 2 cm in diameter, however the depth of the wound is concerning measuring approximately 3.75 cm in depth. The tissue of the wound appears healthy; it's pinkish red, there is no gray tissue, no bleeding noted. Up to this point Hydro Fair Blue has been used for packing of this wound. This resident however has multiple stools a day and the dressings become soiled and has to be changed which limits the effectiveness of the Hydro Fair Blue. Will try to reduce the number of stools a day by adding a bulking agent. Once this resident is not having such frequent stools reevaluation of dressing will be done, in hopes of healing the open area. Measurements/assessments were not documented weekly as follows from: March 17 through March 23, March 24 through March 30, April 21 through April 27, April 28 through May 4 In an interview on 5/6/24 at 2:04 PM, the resident laid on an air mattress with alternating pressure and reported she had a sore to her bottom that she thought she had when she first moved into the facility. The urostomy bag was connected to a large drainage bag with a dignity flap draining clear yellow urine. An observation of wound care on 5/8/24 at 3:41 PM revealed Resident #2 had a pressure ulcer to the coccyx area. The wound appeared to be beefy red, surrounding skin without signs of infection and no odor noted. Staff D, LPN used the correct technique to cleanse the wound and to place Hydrofera Blue dressing into the wound bed covered with dressings soaked in normal saline and Mepilex. In an interview on 5/9/24 at 10:08 AM, Staff E, CNA reported Resident #2 had the pressure ulcer to her coccyx when she was first admitted and she didn't have the air mattress for the first few days. In an interview on 5/9/24 at 10:30 AM, the DON (Director of Nursing) reported the following: a. She was the wound nurse at the facility, she was also the DON, also the MDS Coordinator, Infection Preventionist and Medical Records Coordinator. Because of all these additional tasks that needed to be completed, she became late on documenting the wound assessments. b. All the wound assessments on Resident #2 ulcer were documented in the electronic medical record under the assessment tab. c. The wound should be assessed and measured once a week. In addition to the other job duties she had picked up, she also has to cover the floor when the nurses call in sick. The assessments in the electronic medical records are the only ones that have been completed, I did change her dressing yesterday, the wound used to look gray, now it's looking beefy red and improving. In an interview on 5/8/24 at 10:46 AM, Staff D, LPN reported the following: a. Resident #2 was admitted with her current pressure ulcer b. Nurses should document on the wound weekly. The facility had a wound nurse, who was our MDS coordinator, so now the DON has been the wound nurse, and our nurse practitioner whenever she makes rounds. She's supposed to be here weekly, but not always here weekly c. If the DON is unable to work, he was not sure if her responsibilities were assigned to anyone regarding wound assessments. d. The wound did have depth when she came in, but it wasn't documented. e. When asked what is care planned to keep the wound from growing, he reported Resident #2 has the alternating pressure air mattress which she got within the day she got admitted . Before the alternating pressure mattress arrived, we were floating her, repositioning her from side to side every 2 hours, not supposed to be up in the wheelchair more than 2 hours. In an interview on 5/8/24 at 11:58 AM, Staff B, CNA reported Resident #2 had the wound when she was admitted to the facility and the wound has grown deeper and it has become harder to turn her to her right side because of the pain to her hip. In an interview on 5/13/24 at 9:49 AM, the DON reported the following: a. Resident #2 was not going to a wound care center. b. When Resident #2 first came to the facility, the wound was gray in color and she asked the Nurse Practitioner for an order for normal saline gauze to pack in the wound twice a day. The color of the wound became beefy red, but grew deeper. Orders were written to discontinue the Hydrofera Blue because the depth of the wound wasn't healing. The top of the wound was starting to close before the inner wound healed. Now we're back to the normal saline soaked packing twice daily. In an interview on 5/14/24 at 3:49 PM, the DON reported the following: a. She would expect nurses to document measurements and assessments of pressure ulcers under the assessment tab in the electronic medical record under skin evaluations b. To address the problem of wound assessments not documented weekly, she reported she would make sure that she documents them every week. Upon request of the facility policy on wound care, the facility provided a document titled: Review of Skin Management Standard dated October 2023. It had documentation of the following: a. Complete documentation of the wound assessment in the medical record, numbering each wound. b. Utilizing the information contained in the Weekly Wound Reports review and discusses each wound individually at the weekly Care Management Meeting. c. The interdisciplinary team determines the appropriateness of continuing current treatment or altering treatment, as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interview, and facility policy the facility failed to administer insulin correctly to 1 of 3 residents reviewed for insulin therapy. (Resident#7) The facility staff put Resident#7 at risk for a potential life threatening reaction by combining two types of insulin in the same syringe that are incompatible to be administered together. Findings include: Resident #7's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS further documented the resident had diagnosis including Diabetes Mellitus (DM), morbid obesity and renal (kidney) insufficiency and received insulin during the last 7 days. The Care Plan initiated 1/8/16 for Resident #7 documented the resident had a diagnosis of DM and used insulin to manage her condition. The Care Plan directed staff to provide insulin as ordered by the doctor. Review of Resident #7's March 2023 Medication Administration Record (MAR) revealed the following physician orders: a. Levemir solution 100 Unit/Milliliter (Insulin Detemir) Inject 35 unit subcutaneously at 7:30 AM and 7:00 PM for diabetes mellitus with a start date 9/19/22 b. Novolog solution 100 Unit/Milliliter (Insulin Aspart) Inject as per sliding scale: if 150 - 200 = 2 UNITS; 201 - 250 = 4 UNITS; 251 - 300 = 6 UNITS; 301 - 350 = 8 UNITS, subcutaneously with meals related to Type 2 diabetes mellitus with diabetic chronic kidney with a start date 9/19/22. The March 2023 MAR documented Resident #7 had a blood sugar reading of 151 at 7:30 AM on 3/10/23 and received 2 units of Novolog insulin. During an interview 5/22/23 at 11:50 AM, Resident #7 revealed on 3/10/23 she received 1 insulin injection at 7:50 AM by Staff H, Registered Nurse (RN) and she only remembered 1 needle. The resident revealed at 9:15 AM on 3/10/23 she had a reaction and started shaking and sweating and thought she was nervous and then put two and two together and realized she had a reaction to only receiving 1 insulin injection. The resident stated she asked Staff H the next night about only receiving 1 insulin injection the morning of 3/10/23 and he revealed he had combined the 2 two different insulin's into 1 syringe. Review of facility policy, Medication Administration Guidelines, dated August 2021 revealed definition of an error means any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional. During an interview 5/25/23 at 12:32 PM, the Director of Nursing (DON) acknowledged Staff H, RN had mixed Levemir and Novolog insulin in 1 syringe and administered it to Resident #7 the morning of 3/10/23. The DON further revealed it would be an expectation not to mix Levemir and Novolog insulin into 1 syringe. During communication via electronic mail on 5/30/23 at 12:13 PM the DON revealed 10 residents were scheduled to receive insulin on 3/10/23.