**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to routinely assess and provide interventions for retracting the foreskin of the penis and returning to its original position for 1 out of 3 residents reviewed (Resident #2). Resident #2 required intervention at the Urology Clinic to reduce paraphimosis (foreskin pulled back but unable to return to its original position over the head, or glans, of the penis) on 3 different occasions. This facility reported a census of 52 residents. Findings include: Resident #2's Minimum Data Set assessment dated [DATE], listed an admission from an acute hospital stay on 9/24/24. The MDS identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #2 required substantial assistance with rolling left and right, toileting hygiene, and dressing. The MDS listed Resident #2 had a catheter. The MDS included diagnoses of congestive heart failure (CHF), renal (kidney) insufficiency, chronic obstructive pulmonary disease (COPD), and paraphimosis. A list provided by the facility on 11/25/24 of residents with BIMS scoring 8 or greater reflected Resident #2's score of 13, indicating intact cognition. Resident #2's Hospital Records dated 9/24/24 listed the following physician orders: a. Admit to skilled level of care. b. Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat upon arrival. c. Urology placed a urinary catheter, recommend leaving the catheter in place until the patient is more mobile and penoscrotal (penis/scrotum) edema (swelling) has improved. The Structured Progress Note dated 9/24/24 at 1:29 PM reflected the note as the admission Nursing Assessment. The note indicated Resident #2 had abnormalities, edema, with his genitalia. The note lacked documentation of a catheter. The Health Status Note dated 10/4/24 at 4:50 PM indicated the nurse assessed Resident #2's penis due to a report of it looking swollen. Upon assessment the nurse documented Resident #2 penis as swollen at the base of the tip on top. It looked like a crescent starting from one side and going to the other side of the tip. The note reflected the nurse attempted the doctor's suggestion to try and pull his foreskin back with lubricant, but had no success. The swelling is noted as part of the skin under the foreskin. Underneath his penis looked discolored, he denied pain to area. The doctor directed to send Resident #2 to the emergency room if he started to complain of pain and it started turning purple. The Health Status Note dated 10/6/24 at 6:16 AM written by Staff L, Registered Nurse (RN), indicated the certified nurse aides (CNAs) reported Resident #2 got up to the bathroom multiple times throughout the night. The nurse catheterized him to see if he had residual (urine left in bladder after urinating). The nurse emptied 1,025 milliliters (ml) of urine, and left the urinary catheter left in place. The day nurse would notify family and the provider. The Skilled Note dated 10/10/24 at 10:45 PM identified Resident #2's had 2 plus (+) edema. Urinary catheter remains in place. The Health Status Note dated 10/11/24 at 12:38 PM reflected the facility's Advanced Registered Nurse Practitioner (ARNP) saw Resident #2 on 10/10/24 at the facility. The ARNP wrote orders to use a secure lock for his urinary catheter to prevent pulling. In addition, related to his paraphimosis put an icepack to his groin area for 20 minutes, then try manual manipulation with KY gel. The ARNP planned to see him the next week. The Communication with the Physician Note on 10/13/24 at 9:27 PM indicated the facility faxed an update to Resident #2's primary care provider (PCP) that the current treatment didn't help his paraphimosis. The New Order Follow-Up Note dated 10/14/24 at 9:19 AM reflected Resident #2's urinary catheter drained yellow urine. His penile edema remained. The staff continued to apply ice for 20 minutes and attempted manipulation without success. Resident #2 continued to have flat affect, but compliant with care and assessment stating he'd do what the girls told him. Resident is quiet, responded when spoken to but didn't offer conversation per his usual. The Physician Visit Note dated 10/16/24 at 4:05 PM, indicated Resident #2 returned to the facility without incident from seeing the Urology Clinic Provider ARNP. They ordered medication and directed to follow-up at his appointment on 11/20/24 at 3:00 PM. The nurse updated the Medication Administration Record (MAR), faxed the pharmacy, updated the calendar, and notified his daughter. The Urology Progress Notes dated 10/16/24, identified Resident #2 had urethral (urinary tract opening at end of penis) erosion (breakdown of tissue surrounding the urethra) and paraphimosis. The Urology staff reduced the paraphimosis in the clinic. The Urology team would provide education to the nursing staff at his care facility. The Impression/Plan listed they reduced the paraphimosis at the bedside. They provided education to the nursing home (NH) staff to ensure they retract the foreskin back over the head of the penis after catheter care. The New Order Follow-up Note dated 10/17/24 at 12:43 PM, reflected Resident #2 appeared more tired than usual and would see the facility ARNP the next day on rounds. The Urology Clinic Provider and facility ARNP discontinued the treatment of ice and manipulation. The Communication - with Outside Vendor dated 10/18/24 at 2:06 PM reflected the facility received a fax from the Urology Clinic Provider. The fax identified the Urology clinic would do the next couple catheter changes. Resident #2 would follow up in the office on 10/20/24 at 3:00 PM. The provider gave a new order to apply bacitracin to tip of penis/urethra twice a day (BID) and ensure the foreskin is not behind the head of penis. The note instructed to pull the foreskin back and clean it daily then pull it back over the penile head to prevent edema paraphimosis. A Clinical Physician's Order dated 10/18/24, directed to apply bacitracin (antibiotic ointment) to the tip of the penis twice a day. The order directed the nurses to ensure the foreskin is not behind the head of the penis. The note instructed to pull the foreskin back and clean it daily then pull it over the penile head, twice a day for paraphimosis. In a Urology Clinic Conversation between a Urology Clinic Nurse and the Urology Clinic Provider dated 10/18/24, the provider instructed the Clinic Nurse to make sure the NH staff know they need alternate the catheter so it didn't cause tension. The NH needs an order to apply bacitracin to the end of the penis/urethra twice daily on the sore area. In addition, make sure they know when they do catheter care they must make sure the foreskin is not left behind the head of the penis. Resident #2 had significant swelling/paraphimosis when they saw him from this. They should pull the foreskin back daily and clean with catheter care but the foreskin needed returned over the penile head. The Health Status Note dated 10/28/24 at 12:23 AM reflected Resident #2's penis remained enlarged. The attempts to apply cooling packs and ointment to get the foreskin over the head of penis without success. Resident #2 became very tearful at times. The Health Status Note dated 10/28/24 at 10:03 PM indicated Resident #2's penis remained full of fluid. Resident #2 denied discomfort or pain. The Health Status Note dated 10/30/24 at 11:01 PM, reflected the nurse applied triple antibiotic to tip of Resident 2's penis. The head of his penis remained enlarged. The staff provided peri care and attempted to pull his foreskin over his penis without success. The Physician Visit Note dated 10/31/24 at 2:43 PM identified the facility ARNP saw Resident #2 and ordered labs. The Communication - with Physician dated 10/31/24 at 2:54 PM, indicated the facility called the Urology Clinic to report edema to Resident #2's foreskin of his penis. The Urology Clinic Provider would see Resident #2 the next day on 11/1/24 at 9:00 AM. The Health Status Note dated 10/31/24 at 11:36 PM reflected the staff provided catheter care. His penis remained swollen and they couldn't to pull foreskin over the penis head. The Appointment Note dated 11/1/24 at 8:15 AM identified Resident #2 left the facility via van to an appointment with his Urology Clinic Provider. The Appointment Note dated 11/1/24 at 9:55 AM, indicated Resident #2 returned to the facility. The Communication Sheet lacked notes, transportation reported the clinic would call. A Urology Clinic Progress Note dated 11/1/24, reflected the reason for Resident #2's visit as his foreskin retracted and the NH unable to get it back in place. It caused pain and paraphimosis. The clinic saw Resident #2 that day for penile pain and swelling. The NH called the previous day and reported his foreskin was retracted and they couldn't get it back over the head of his penis. The Urology Clinic Provider managed to manipulate the foreskin back. The clinic called the NH and gave instructions to Staff G, Licensed Practical Nurse (LPN). The instructions were to avoid fully retracting the foreskin all the way behind the glans, only pull back enough to clean, apply ointment, and place back. Staff G verbalized understanding and thanks. The Health Status Note dated 11/6/24 at 11:13 PM identified Resident #2's penis didn't have redness. The staff applied ointment as ordered. The catheter patent (in place and working) at the time with urine in the drainage bag. The Health Status Note dated 11/11/24 at 11:03 PM indicated Resident #2's penis remained swollen. The staff completed his treatments as ordered. The New Order Follow-Up Note dated 11/12/24 at 7:02 AM reflected Resident #2's penile edema remained. Resident #2 denied complaints of pain/discomfort. The Skin Condition Note dated 11/14/24 at 4:00 PM identified the facility completed the weekly skin assessment. The note lacked information regarding Resident #2's penis or scrotum. The Health Status Note dated 11/15/24 at 7:42 PM indicated Resident #2 didn't have a sore on his penis. The Health Status Note dated 11/18/24 at 10:17 PM reflected Resident #2 continued to have large amounts of edema in his lower body, as well as penile edema. The New Order Note dated 11/20/24 at 4:37 PM identified Resident #2 returned from his urology appointment. The instructions directed to continue with routine monthly catheter changes. In addition, nursing must pull the foreskin back over the head of penis after peri-cares. The Health Status Note dated 11/20/24 8:00 PM indicated Resident #2's penis remained swollen. The attempt to bring his foreskin over the penis failed. The Urology Progress Notes dated 11/20/24 identified Resident #2 as well since his last visit, but again noted to have paraphimosis. The clinic has instructed the staff at his nursing facility on 2 separate occasions to make sure they pull the foreskin back over the penile head with peri-care, however, it appeared that didn't happen. The clinic would reach out again to the facility with proper instructions. Resident #2's October 2024 and November 2024 Treatment Administration Records (TARS) reflected the nurses started signing on 10/18/24 at his hour of sleep (HS) that they applied bacitracin to the tip of the penis twice a day. The documentation reflected the nurses signed they ensured the foreskin wasn't behind the head of the penis, it should be pulled back, and cleaned daily then pulled forward over the penile head. On 11/25/24 at 10:32 AM, the Urology Clinic Nurse stated they saw Resident #2 three times at their Urology Clinic. She stated all 3 times Resident #2 had paraphimosis that the clinic's provider had to reduce. The Urology Clinic Nurse stated she talked with the NH's Director of Nursing (DON) on 10/16/24 and discussed the clinic's concerns. The Urology Clinic Nurse stated at the 11/20/24 visit, it took approximately 10 minutes to reduce the paraphimosis. She described the reduction of the paraphimosis (pulling the foreskin back into place over the penile head) as painful and almost like torture for him. On 11/25/24 at 10:44 AM, the Urology Clinic Provider stated the first visit they had with Resident #2 happened on 10/16/24, he had a catheter in place. Resident #2 had erosion of the penis, edema, and paraphimosis. The Urology Clinic Provider stated the erosion looked like it started from the catheter tension to the urethra. On 11/1/24, Resident #2 had paraphimosis again and the Provider was able to reduce it. The Provider called and told them to only pull the foreskin back enough to clean the head and apply ointment then put foreskin back over the glans penis. On 11/20/24 the Urology Clinic Nurse described Resident #2's penis as significantly swollen again with the foreskin stuck behind the glans. Resident #2 didn't have his catheter connected properly to the leg and caused tension. It was very painful for him. The Urology Clinic Provider stated they didn't have any way to know how long he had his foreskin pulled back. The Urology Clinic Provider stated Resident #2 already had CHF so he would already have more swelling to that area. Resident #2 told the clinic staff that he had pain since the last time he came to the clinic. The Urology Clinic Provider reported they had a lot more difficulty with getting his foreskin back in place on that visit then his prior visits and he had extreme pain. The Urology Clinic Provider described Resident #2 as not one to complain. The Urology Clinic Provider stated she called the facility and gave education every time and sent orders. She didn't know if the facility needed more education or what. The Urology Clinic Provider reported it as concerning that he had paraphimosis on all of 3 of his visits. On 11/25/24 at 1:30 PM, Resident #2 and his wife sat in their room together. They gave permission to enter the room and close the door. Resident #2 stated he didn't have any pain. He nodded in agreement when asked about the 3 times the Urology Center had to move the foreskin back over the head of his penis. He said the girls do a good job at the facility and the only time he had pain happened when they cleaned him up down there. He stated they did those cares in the morning and in the evening. He stated he believed his foreskin was, at this time, over the head of his penis and his wife agreed. Resident #2 gave permission to observe peri-care in the morning. On 11/25/24 at 7:32 PM, Staff E, LPN, stated she knew Resident #2 returned with a doctor's order instructing the aides only to pull the foreskin back so far. Staff E stated they used ice packs and ointment to try to get the foreskin back over the glans penis. Staff E stated Resident #2 didn't say anything about being in pain. She described his foreskin as just a tiny bit past the head of the penis. She stated the penis didn't change colors at all. Staff E reported to her knowledge the Urology Clinic didn't ever get the foreskin back over the head of the penis. She stated the past week was the first time the Urology clinic ever got the foreskin back over the head of the penis. Staff E said she never saw Resident #2's foreskin pulled back into place until the prior week. Staff E said to her knowledge the other 2 times Resident #2 went to Urology, they couldn't get the foreskin back into place. When they said they did, Staff E said she never saw it. When asked when would it be considered urgent to send Resident #2 out, Staff E replied if his penis turned blue or something like that. Staff E said they tried to make the swelling go down with an ice pack and putting the lubrication on it. She said the TAR included that treatment. Staff E stated they checked his penis and foreskin every night. Staff E said she taught a new CNA how to do it appropriately. Staff E said the CNA told her they never learned how to pull the foreskin back in place in school. So, Staff E showed the CNA how to do it. Staff E couldn't remember the name of the CNA. Staff E couldn't believe they didn't teach the CNA that in school. On 11/25/24 at 7:41 PM, Staff F, LPN, reported she knew when Resident #2 first came to the facility he had a fluid filled (edema) area on the shaft of his penis. Staff F described it as hard to get the foreskin to retract and go back over the head of Resident #2's penis. Staff F stated Resident #2 always had sensitivity down there. She said it didn't look like the swelling came from trauma. Staff F stated she always could get the foreskin retracted back from the head of his penis and then back over the head of the penis. Staff F said Resident #2 never complained (of pain) to her. Staff F stated she only worked at the facility as needed (PRN), like 2 or 3 times a month. She only worked with Resident #2 a couple of times. Staff F never saw any of the moments where the foreskin couldn't be pulled back into place over the head of the penis. Staff F never saw any difficulties with the CNAs being able to replace the foreskin back over the head of the penis. Staff reported they went with the CNAs because they had to apply the bacitracin on to the tip of Resident #2's penis. Staff F stated it took a few more steps to get the foreskin retracted and then pulled back over into place related to the swelling. Staff F stated Resident #2 could voice his concerns and he would voice if he had pain. On 11/26/24 at 7:15 AM, observed Staff H, Certified Medication Aide (CMA)/CNA, and Staff I, CNA, provide morning care for Resident #2. Observed edema in his lower legs and feet. During the peri-care/catheter care witnessed Resident #2's foreskin retracted half way down the head of his penis, they cleaned the penile head, and returned the foreskin back in place. The observation showed no redness, discharge, or swelling. The DON applied the bacitracin to the penis after retracting the foreskin and then she pulled the foreskin back over the glans. On 11/26/24 at 8:00 AM, Staff H and Staff I stated they both received training on how to do peri care on an uncircumcised resident. They both said they had to corrected their peers at times for not pulling the foreskin back over the head of the penis and/or not retracting the foreskin to clean the head of the penis. Staff I explained if they don't retract the foreskin to clean, then discharge can build up under the foreskin, which could result in it becoming cheesy and yellow. They didn't see anything recently where they needed to intervene with the staff. Staff H stated Resident #2 came into the facility with the foreskin retracted and the head of his penis swollen. She stated she thought he went to have it taken care of about 1 week after he got to the facility. On 11/26/24 at 8:25 AM, Staff J, CNA, stated she received training on how to clean an uncircumcised penis. She stated when Resident #2 first came into the facility, Staff J couldn't tell if Resident #2 was circumcised or not because of the swelling in his penis. In addition, she couldn't tell if he even had a foreskin. Staff J stated Resident #2 retained a lot of water. She stated she gave him a bath the previous Sunday (11/24/24) and his penis looked swollen but he had the foreskin pulled over the head of his penis. On 11/26/24 at 8:40 AM, Staff K, CMA/CNA, reported she learned how to provide peri care to uncircumcised males. She explained the process as you need to pull the foreskin back, cleanse the penis, and then replace the foreskin back over the penis. She described Resident #2's penis as swollen. Staff K saw him with his foreskin pulled back behind the head of the penis, when they couldn't pull it back over the penis. She estimated it was probably the previous week, but she didn't know a certain day. She stated when she realized this she went and told the nurse. She stated she didn't observe any of her peers leaving the foreskin down. She stated they used to be able to take the foreskin down, clean the head of the penis, and then pull the foreskin back up, but then his penis started swelling. She didn't know when or who pulled the foreskin down and didn't get it back up over the head of his penis. On 11/26/24 at 11:46 AM, the DON reported he didn't document the conversation she had with the Urology Clinic on 11/20/24 and 11/21/24 as it just happened. She stated she would document the conversation. When asked about the admission order to remove the catheter after his penile and scrotal swelling decrease, but his clinical record lacked documentation of penile and scrotal swelling until 10/4/24 with exception of a mention in an admission note, she responded it would be in the daily skilled documentation. When asked about Resident #2 having paraphimosis on 10/16/24, she replied she would look into it more. When asked how the nurses signed that they applied the bacitracin BID to the tip of his penis and ensured they pulled the foreskin back over the head of his penis, but, Resident #2 went out again on 11/1/24 and 11/20/24 with paraphimosis, the DON responded she needed to look into it more. She stated that since changing corporations, they updated the systems and they are looking into getting information that the survey team requested. She reported she understood the concern with the lack of documentation of assessments and interventions. On 12/3/24 at 3:55 PM, Staff L, RN, stated Resident #2 had a lot of edema to his penis in general as well as the foreskin and the shaft. Staff L stated Resident #2 had an issue with his foreskin for a long time. The staff pulled it back to perform peri-care and then they couldn't get it back over because of the swelling. She stated this already happened when she started working with him. Staff L said her first encounter with Resident #2 happened when she catheterize him on 10/4/24. Staff L noticed his foreskin retracted and they couldn't pull it back over the head of the penis. Staff L stated if his penis was like that prior to Staff L putting the catheter in, she didn't know of it. Staff L didn't recall when they put the bacitracin order in place. After the beginning of November, when Staff L went back to day shift, he already had the order to apply bacitracin to his penis in place. Staff L stated she applied the bacitracin to Resident #2 multiple times. He had foreskin retracted where it couldn't be pulled back over, except right before he moved to the back on 11/26/24, somebody did get it back over the penis head. The majority of the time his penis had too edema and it hurt him, the facility staff couldn't get the foreskin back over. Staff L noticed one time he had his foreskin back over the head of his penis. Luckily on that day she could pull the foreskin back, do his treatment, and replace the foreskin back over the penis. Staff L stated she didn't recall if the bacitracin order directed to pull the foreskin back over the head of the penis. Staff L said she didn't remember his penis being discolored at all. Staff L stated she didn't know if anyone reported it to the Provider. Staff L stated he already had the issue when she went to the day shift. Staff L said if somebody reported the issue it wouldn't been her. Staff L reported it as questionable too, how long it had been like that. She said she believed that at one of his Urology appointments, they couldn't pull the foreskin back over. When told the documentation showed they did reduce the paraphimosis at all 3 of his appointments, she responded after he came back from one of his appointments, she didn't know if it was that same day or the next morning when she did the treatment, she looked at it and they didn't get the foreskin back over. When read the 11/20/24 progress note to Staff L, she replied she may have said that wrong. Staff L stated she saw issues with not being able to pull his foreskin over the glans prior to 11/20/24. Staff L stated she worked on 11/22/24 and described his penis as edematous, during care, treatment, and retracting of the foreskin back over the head of his penis. Staff L stated she didn't believe she knew the bacitracin order directed to pull the foreskin back over the glans penis. Staff L explained ideally, they would perform the necessary cares and treatment. In Resident #2's case, he had a very painful and edematous penis. Staff L stated she didn't remember Urology telling them know how to decrease the edema. Staff L stated in Resident #2's case, they thought they would do more damage to him to try and force the foreskin back over the head of the penis then to leave it. He didn't really complain much but they could tell that it was tender, and when they tried to pull the foreskin back over the penile head, it caused him pain. Staff L reported she would probably described it as tender because of the edema with the foreskin pulled back. He didn't complain of it bothering him on a day to day basis when they had issues. Staff L wondered if the facility could do something. Staff L said that after his last Urology appointment, the DON told them Urology called. She explained they were really mad and wanted to know if staff didn't clean him well, or what the problem was because they had to pull his foreskin back again over the head of his penis. The DON wanted 2 nurses to do Resident #2's peri-care to ensure the foreskin got put back into place. Staff L described it as very frustrating. On 12/4/24 at 2:13 PM, Staff M, LPN, stated she didn't remember for sure the first time she got report of Resident #2's retracted foreskin. The facility ARNP told Staff M to ice and elevate the penis, then try to retract. Staff M stated the Facility ARNP said if Staff M could get the swelling down then to use ointment to try and pull the foreskin back over. Staff M stated they couldn't get the swelling down. Staff M stated the ice and elevation didn't work. Staff M stated she told the Facility ARNP, who made a Urology appointment. Staff M stated Resident #2 never really complained of pain. She said that Urology told them to use bacitracin and that didn't really work to get the foreskin back over. Staff M said she knew Resident #2 had a history of paraphimosis and swelling. Staff M wondered if the catheter was a contributing factor to the swelling and paraphimosis. Staff M stated she made sure the staff did proper catheter care. Staff M didn't see any concerns with the CNAs providing care. Staff M didn't recall talking to the Urology Clinic Provider or anyone about anything other than to schedule the appointment. Staff M stated they couldn't return the foreskin back over the head of the penis at the facility. When the documentation was read to Staff M that the Urology Clinic Provider wrote they talked to Staff M, she responded she didn't remember talking to anyone on the phone. She explained she didn't say it didn't happen, she just didn't remember it. Staff M stated she remembered an order basically saying the same thing read to her. Staff M stated they looked into his visits, they didn't remember the date, but they wrote a note to not fully retract the foreskin. Staff M stated she applied bacitracin to his urethra several different times. Staff M acknowledged she knew the order directed to pull the foreskin back over the head of the penis after applying the bacitracin. Staff M stated she honestly didn't know if she called a physician/provider to let them know the nurses couldn't get the foreskin back over the penile head. Staff M stated she knew she talked to the Facility ARNP about it at different times. Basically, we had the bacitracin order and he went to urology. Staff M stated they could try ice too. When asked if she should have called a provider she said yes. She stated at the time, because it wasn't new, she just . She added again it wasn't new. On 12/4/24 at 3:36 PM, the Facility ARNP stated she knew she saw Resident #2 in October. They had difficulty getting his foreskin back over the penile head. The Facility ARNP believed she ordered a consult to Urology at that time. The Facility ARNP stated she didn't know that the paraphimosis was persistent and stated she didn't receive any calls from the facility regarding his ongoing paraphimosis. She stated she is available all the time and the facility's nurses didn't call her reporting persistent paraphimosis. She acknowledged the bacitracin order was to ensure they could move the foreskin back into place twice a day and acknowledged no one notified her that they couldn't get it back. The Facility ARNP stated Resident #2 had a urinary catheter that drained correctly. On 12/4/24 at 4:35 PM, the Administrator and the DON, stated periodically the nurses couldn't pull Resident #2's foreskin back into place, but not always. When informed about the concern of nurses documenting twice a day they pulled the foreskin back over the head of the penis after retracting it to apply ointment, and the facility ARNP stated no one contacted her regarding not being able to pull the foreskin back over the head of the penis, nor did she know he had this as a persistent problem, the DON and the Administrator acknowledged the concern. The DON and Administrator couldn't provide any further information regarding documentation of the penile/scrotal swelling . The DON didn't provide the documentation from the conversation she had with the Urology Clinic. The facility couldn't provide any additional documentation from the skilled daily nursing notes. The facility stated they follow the standard of practice for assessment, intervention, following doctor's orders, and peri care on un circumcised males.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to follow standards for bladder care and services for 2 out of 3 residents reviewed (Residents #1 and #2). Resident #2 had a voiding trial (trial to see if resident could go without a catheter to drain the urine from his bladder) without measuring output or documenting his output for 1 shift. Resident #2 couldn't urinate on a separate shift and had over 1 liter of urine drained from his bladder. Resident #2 had urethral erosion (tissue breakdown around the urinary meatus, opening at the end of the penis) from a Urinary catheter (tube placed in the urethra to drain urine out of the bladder). The facility failed to ensure Resident #2 wore a secure device to hold the catheter in place and to prevent pulling on the catheter. The facility failed to provide timely incontinence care to Resident #1. The facility reported a census of 52 residents. Findings include: 1. Resident #2's Minimum Data Set assessment dated [DATE], listed an admission from an acute hospital stay on 9/24/24. The MDS identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #2 required substantial assistance with rolling left and right, toileting hygiene, and dressing. The MDS listed Resident #2 had a catheter. The MDS included diagnoses of congestive heart failure (CHF), renal (kidney) insufficiency, chronic obstructive pulmonary disease (COPD), and paraphimosis. Resident #2's Hospital Records dated 9/24/24 listed the following physician orders: a. Admit to skilled level of care. b. Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat upon arrival. c. Urology placed a urinary catheter, recommend leaving the catheter in place until the patient is more mobile and penoscrotal (penis/scrotum) edema (swelling) has improved. d. Recommend voiding trial at nursing facility in 3 to 4 days. The orders repeated to please do a voiding trial at nursing facility in 3 to 4 days to remove the urinary catheter. The Care Plan Focus initiated 10/8/24 indicated Resident #2 required the use of an indwelling catheter related to obstructive uropathy (blocked urinary passage). The Interventions directed staff to use a catheter securement device. The Structured Progress Note dated 9/24/24 at 1:29 PM reflected the note as the admission Nursing Assessment. The note indicated Resident #2 had abnormalities, edema, with his genitalia. The note lacked documentation of a catheter. The Structured progress notes on 9/26/24 at 4:16 PM, 9/27/24 at 7:46 PM, 9/28/24 at 8:06 PM, 9/29/24 at 10:16 PM, and 9/30/24 at 8:58 PM indicated Resident #2 had an indwelling catheter. The Skilled Note on 10/1/24 at 9:57 PM reflected Resident #2's urinary catheter remained. The New Order Note dated 10/2/24 at 4:18 PM indicated the facility received new orders to remove Resident #2's urinary catheter from the physician. The orders directed if once removed Resident #2 can't void within 8 hours, replace the urinary catheter and notify the provider then refer to urology. The Skilled Note dated 10/2/24 at 10:24 PM reflected they took out the catheter as ordered and gave Resident #2 a urinal. The Skill Note dated 10/2/24 at 11:44 PM, indicated the staff provided 100% assistance with urinary catheter management. The Health Status Note dated 10/6/24 at 6:16 AM written by Staff L, Registered Nurse (RN), reflected the certified nurse aides (CNAs) reported to the nurse Resident #2 went to the bathroom multiple times throughout the night. The nurse catheterized Resident #2 to see if he had residual (urine remaining after voiding), he had 1,025 milliliters (ml) of urine out. The nurse left the urinary catheter in place. The day nurse would notify the family and provider. The General Progress Note dated 10/6/24 at 9:27 PM identified Resident #2's urinary catheter as intact and patent (in place and working). The urinary output appeared clear and yellow with adequate output noted. Resident #2 denied pain/discomfort with the re insertion of his catheter. The Health Status Note 10/7/24 at 10:27 PM, identified Resident #2 had a large amount of urine in his bag (3/4 full at 8:00 PM) that night. The nurse asked the staff to empty the catheter bag. The Skilled Note dated 10/7/24 at 11:14 PM indicated Resident #2's urinary catheter remained in place. The New Order Follow-up Note dated 10/8/24 at 9:43 AM identified Resident #2 had a catheter in place, patent, and draining clear yellow urine. The Skilled Note dated 10/8/24 at 7:51 PM indicated Resident #2's urinary catheter remained in place. The New Order Follow-up Note dated 10/9/24 at 12:10 PM reflected Resident #2 had a patent catheter draining clear yellow urine. Resident #2 reported he didn't feel the urge to go constantly, like he did before. He explained he actually could get some sleep. No tearfulness observed on assessment. The Skilled Note dated 10/9/24 at 6:57 PM indicated Resident #2's urinary catheter remained in place. The Health Status Note dated 10/9/24 at 9:08 PM identified Resident #2 had a patent catheter draining clear yellow urine. He denied urinary discomfort. The New Order Follow-up Note dated 10/10/24 at 7:10 AM, reflected Resident #2 reported he had relief when they placed the catheter as he didn't have the constant urge to urinate. The Skilled Note dated 10/10/24 at 10:45 PM, identified Resident #2's scrotum had 2+ edema and his urinary catheter remained in place. The Health Status Note dated 10/11/24 at 12:38 PM reflected the facility's Advanced Registered Nurse Practitioner (ARNP) saw Resident #2 on 10/10/24 at the facility. The ARNP wrote orders to use a secure lock for his urinary catheter to prevent pulling. In addition, related to his paraphimosis put an icepack to his groin area for 20 minutes, then try manual manipulation with KY gel. The ARNP planned to see him the next week. The Skilled Note dated 10/11/24 at 11:31 PM indicated Resident #2's urinary catheter remained in place. The Skilled Note dated 10/12/24 at 7:32 PM indicated Resident #2's urinary catheter remained in place. The Skilled Note dated 10/13/24 at 11:53 PM, indicated Resident #2's urinary catheter remained in place. The Communication - with Outside Vendor dated 10/18/24 at 2:06 PM reflected the facility received a fax from the Urology Clinic Provider. The fax identified the Urology clinic would do the next couple catheter changes. Resident #2 would follow up in the office on 10/20/24 at 3:00 PM. The provider gave a new order to apply bacitracin to tip of penis/urethra twice a day (BID) and ensure the foreskin is not behind the head of penis. The note instructed to pull the foreskin back and clean it daily then pull it back over the penile head to prevent edema paraphimosis. Resident #2's October 2024 Documentation Survey Report related to bladder elimination report lacked documentation on the night shift of 10/4/24. The report didn't document the amount of urine output for each shift. It documented Resident #2 had a catheter in on 10/2/24 and 10/6/24 on the first shift. The documentation between the two shifts reflected Resident #2 as continent or incontinent, with the exception of the 10/4/24 night shift due to no documentation. The Clinical Physician's Order printed 12/3/24 included an order by the Facility Advanced Registered Nurse Practitioner (ARNP) dated 10/11/24 entered in the electronic health record by the Director of Nursing (DON), to place a urinary catheter secure lock to prevent pulling of the catheter two times a day (BID) for catheter safety. Resident #2's October 2024 and November 2024 Treatment Administration Records (TARs) reflected the nurses started signing on 10/11/24 at bedtime (HS) twice a day that he had a secure lock in place. In addition, the TARs reflected the nurses started signing on 10/18/24 at HS that they applied bacitracin to the tip of his penis twice a day. The documentation reflected the nurses signed they ensured the foreskin wasn't behind the head of the penis, it should be pulled back, and cleaned daily then pulled forward over the penile head. The Clinical Physician Orders dated 10/18/24, directed to apply bacitracin (antibiotic ointment) to the tip of the penis twice a day. The order directed the nurses to ensure the foreskin is not behind the head of the penis. The note instructed to pull the foreskin back and clean it daily then pull it over the penile head, twice a day for paraphimosis. The Urology Progress Notes dated 10/16/24, identified Resident #2 had a recent hospitalization and had urinary retention. They placed a urinary catheter and started tamsulosin. The facility reported conducting 2 separate voiding trials without success. After further discussion with him and his daughter, they attempted a voiding trial, however, he couldn't urinate. They discussed starting a catheter and adjusting his medications. They planned to do a follow-up voiding trial in one month. If unsuccessful at that time, they would start a permanent catheter that the nursing home (NH) could change monthly. He is not a surgical candidate and not interested in surgery. He didn't have hematuria or urinary tract infection issues. He did have urethral (urinary tract opening at end of penis) erosion (breakdown of tissue surrounding the urethra) and paraphimosis (foreskin pulled back but unable to return to its original position over the head, or glans, of the penis). The Urology staff reduced the paraphimosis in the clinic. The Urology team would provide education to the nursing staff at his care facility. The Impression/Plan listed they reduced the paraphimosis at the bedside. They provided education to the nursing home (NH) staff to ensure they retract the foreskin back over the head of the penis after catheter care. The Urology Clinic would do the next couple of catheter changes. In a Urology Clinic Conversation between a Urology Clinic Nurse and the Urology Clinic Provider dated 10/18/24, indicated the facility needed urinary catheter instructions sent to them. In addition, the provider instructed the Clinic Nurse to make sure the NH staff knew they needed to alternate the catheter so it didn't cause tension. The NH needs an order to apply bacitracin to the end of the penis/urethra twice daily on the sore area. In addition, make sure they know when they do catheter care they must make sure the foreskin is not left behind the head of the penis. Resident #2 had significant swelling/paraphimosis when they saw him from this. They should pull the foreskin back daily and clean with catheter care but the foreskin needed returned over the penile head. A Clinical Physician's Order dated 10/18/24, directed to apply bacitracin (antibiotic ointment) to the tip of the penis twice a day. The order directed the nurses to ensure the foreskin is not behind the head of the penis. The note instructed to pull the foreskin back and clean it daily then pull it over the penile head, twice a day for paraphimosis. The Urology Progress Note dated 11/20/24, reflected the staff provided urethral erosion education to the NH staff, apply bacitracin BID, and adjust the urinary catheter to avoid tension on the catheter. On 11/26/24 at 7:15 AM, observed Staff H, Certified Medication Aide (CMA)/CNA, and Staff I, CNA, in Resident #2's room to provide his morning care. When they rolled Resident #2 to his left side, he had his catheter bag attached to the right side of the bed with the tubing taunt (pulled tight). The Director of Nursing (DON) entered the room to apply bacitracin to the glans penis, and noted the tight tubing. She grabbed the tubing and pulled on the bag side to provide slack to the catheter insertion site of Resident #2's urethra, then they placed the catheter bag on the bed. The DON applied the bacitracin to the penis after retracting the foreskin and then she pulled the foreskin back over the glans (head of the penis) after applying the bacitracin. The DON stated something about a secure lock for him when they took the slack out of the tubing. She left and retrieved a secure lock then applied it to his right leg, removed the catheter from the catheter strap on the left leg and placed the tubing in the secure lock. She then moved the leg strap over to the right leg as well, right below the secure lock and put the tubing through the catheter strap as well. When asked who can apply the secure lock the DON replied it wasn't licensed. Both the CNA and the CMA stated they never put a secure lock on a resident before. Unable to visualize Resident #2's full urethra as they didn't fully pull down the foreskin over the glans penis. On 11/26/24 at 8:00 AM, Staff H and Staff I both stated they didn't like working with the catheter lock device the DON placed on Resident #2. On 11/26/24 at 8:25 AM, Staff J, CNA, stated when Resident #2 first came into the facility, they couldn't tell if Resident #2 was circumcised or not due to the swelling in his penis and she couldn't tell if he had foreskin. The CNA stated Resident #2 retained a lot of water. She stated she gave him a bath the previous Sunday (11/24/24) and his penis looked swollen but he had his foreskin pulled over the head of the penis. When asked about the secure locks, she said she hated those things. She said the facility normally didn't put the secure locks on but residents who come from the hospital wore them. Staff J stated that, in fact, Resident #2 had one on the day she gave him a bath, but she took it off and put a catheter strap on him instead because they are more comfortable for the resident and they didn't have the risk of spinning the tubing. She said the secure lock on Resident #2 caused the tubing to be too tight on his leg. When asked how they knew what each resident needed and what they are Care Planned for, she said it's in the tablets, such as if they had a catheter or how they transfer. She added at the beginning of each shift the nurse would let them know if about any changes to the residents' plan of care. On 11/26/24 at 11:46 AM, the DON reported she didn't document the conversation she had with the Urology Clinic on 11/20/24 and 11/21/24 as it just happened. She stated she would document the conversation. When asked about removal of the catheter on 10/2/24 and then Resident #2's clinical record didn't have anything documented about outputs or tolerance until 10/6/24 when the nurse did a residual and he voided over 1 liter of urine, she replied she would look into it. She stated since changing corporations, they updated the systems and they are looking into getting information that the survey team requested. She reported she understood the concern with the lack of documentation of assessments and interventions. On 12/3/24 at 3:55 PM, Staff L, RN, reported she had her first encounter with Resident #2 when she catheterized him. Staff L reported she worked as the overnight nurse in the back area of the facility until November 1st. It happened very early in the morning when the CNAs came to her and told her Resident #2 wasn't urinating. Staff L said Resident #2 kept saying to the CNAs that he had to go to the bathroom and he kept trickling urine. That's when Staff L looked into it more and discovered Resident #2 was on a voiding trial. Staff L went ahead and catheterized Resident #2. She got over 1,000 milliliters (ml) out. Staff L left the catheter in and the dayshift nurse Staff M, LPN, was to call the physician. It was around 6:00 AM when they asked if Resident #2's clinical record had documentation for the voiding trial. Staff L stated she didn't know what they were doing as far as monitoring because she was the night shift nurse for the back. Staff L stated that usually, for a trial, the nurses ask the staff or resident, if they could tell them, if they are voiding. Staff L stated she read the order that night, and that's how she knew. Staff L stated she knew that they told her in report they removed his catheter. Staff L saw the order that directed if he didn't void in 8 hours or something like that to place a catheter. That's when Staff L inserted a catheter for Resident #2 and he had residual urine. On 12/4/24 at 2:13 PM, Staff M stated she knew Resident #2 had a sticky strap (catheter tubing holder) when he first came in and they switched it to a catheter strap. On 12/4/24 at 4:35 PM, the Administrator and the DON, stated they didn't have further information on Resident #2's voiding trial as they sent what they had which was mostly the CNAs documentation on output. The DON stated that a secure lock meant a leg strap. When asked if she had a policy on that, she stated no, it's a standard of practice. When asked if leg straps are Care Planned on residents with catheters, she stated no. When asked if an order is needed for a leg strap she said no. When asked why she wrote an order then for a Secure Lock, this DON stated she didn't remember writing an order for a Secure Lock. She checked another resident's (who also had a catheter) doctor's orders to see if he had a secure lock order, and he didn't. Information was then requested from the Administrator and the DON, to be sent that would show a secure lock was the same as a catheter leg strap. When shared the concern regarding a delay in the start of a voiding trial, a shift going without documentation of whether or not he voided, and Resident #2 ending up retaining over 1 liter of urine, they acknowledged the concern. When shared the concern regarding the observation of the pulling of Resident #2's catheter during care and no secure lock in place at the time, the DON and Administrator acknowledged the concern. The DON acknowledged walking in during the care, noticing the tension on the catheter tubing and relieving the tension on the tubing. The DON acknowledged she then left the room and grabbed a Stat Lock (secure lock), then placed it on his leg and also applied the catheter leg strap on his leg attaching the catheter tubing to both of the devices. This DON acknowledged Resident #2 had urethral erosion. As of 12/5/24 at 4:30 PM, the facility provided no regarding a secure lock. On 12/5/24 at 3:12 PM, the Facility's ARNP responded the secure lock she ordered was for a stat lock device, as they are the same thing. The facility stated they follow the standard of practice for following doctor's orders. 2. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. Resident #1 required supervision/touching assistance with toileting transfers and partial/moderate assistance with toileting hygiene. The MDS listed Resident #1 as frequently incontinent of bowel and bladder. The MDS included diagnoses of hypertension (high blood pressure), renal disease (kidney), cerebrovascular accident (CVA), non Alzheimer's dementia, Parkinson's disease, and neurocognitive disorder with Lewy bodies (a type of dementia). The Care Plan Focus with a target date of 12/24/24 reflected Resident #1 required assistance with activities of daily living (ADL's) related to neurocognitive disorder with Lewy bodies, possible stroke, confusion and weakness. The Care Plan Interventions directed the staff the following: a. Provide extensive assistance from 1 staff member for toileting needs. b. See if Resident #1 was incontinent, aid with incontinence cares, and changing incontinence products. The Care Plan lacked direction on how often to check Resident #1 for incontinence. On 11/25/24 at 8:22 AM, Resident #1's daughter reported she came to the facility on 9/21/24 in the afternoon. She stated the staff told her that her dad was sleeping and they couldn't get him up. She stated she returned to the facility later that evening and found her dad in a urine-soaked bed. She stated the aide (Staff B) cried because of it. On 11/25/24 at 4:35 PM, Staff B, CMA, described Resident #1 as combative and resistant to care at times. Staff B stated the Assistant Director of Nursing (ADON) called her into Resident #1's room to help with incontinent cares. She stated Resident #1's daughter was present. Staff B reported Resident #1 stayed in bed all day. Staff B reported Resident #1 looked like nobody touched him all day. She described Resident #1's clothes and bedding as soaked with urine. She stated Resident #1 had urine from the back of his knees to his hair line. Staff B reported she broke down and started crying. She stated she cleansed Resident #1's back side and changed his bedding. She stated she had to wipe down the bed with a sanitizing wipe. She reported confusion on why the other aides didn't tell her no one changed Resident #1 or did his care. She stated she didn't understand why the other aides didn't take care of Resident #1 themselves or tell her so she could. She stated reported there was a big difference between being in bed all day and not receiving care. On 11/26/24 at 8:12 AM, the ADON reported she expected the staff to complete incontinence care and check on the residents every 2 hours and as needed (PRN). The ADON reported they had a time when they didn't perform incontinence cares for Resident #1 and the facility took disciplinary actions. She explained the 2 10 shift was involved and the first shift may have been a contributing factor. The ADON reported she came in to work at 6 PM and around 6:30 PM, she observed Resident #1 laying in a wet bed full of urine. She described Resident #1 as very sleepy (lethargic) and he didn't get up that day. She couldn't recall if Resident #1 ate or not that day. She stated it was common for Resident #1 to have days where he was sleepier than others. She identified herself as the one to issue the disciplinary actions with the staff members who were involved. On 11/26/24 at 8:16 AM, Staff C, CNA, reported Resident #1's daughter came to the facility and told the staff to leave Resident #1 be as he slept. Staff C described Resident #1 as very noncompliant with his care. She stated she worked 6 AM to 6 PM that day. Staff C reported she went in Resident #1's room approximately every 2 hours to check on him. Staff C stated she asked Resident #1 if she could change him and he told her no, he wanted to be left alone. She stated it was uncommon for him to be in bed and not get up. She stated he didn't eat either. She stated Resident #1's daughter instructed her to let him sleep. Staff C reported she received a write up for not completing incontinence care. She stated she wrote a statement on the write up that the daughter wanted him to be left alone. A facility form titled Employee Counseling form dated 9/21/24 for Staff B, Staff C, and Staff D listed the problem as providing and assisting Resident #1 with incontinence cares approximately every 2 hours or as needed. The form described Resident #1 as laying in urine-soaked bedding from head to toe at 6 PM. The counseling forms documented the following employee statements: a. Staff B documented she received report at 2 PM that Resident #1's daughter stated he was comfortable sleeping, leave him because he had an eventful night before. b. Staff C documented Resident #1's daughter told them not to mess with Resident #1. c. Staff D documented multiple people, multiple times tried to get Resident #1 changed, but he refused. Resident #1's daughter came and she told them to leave him and let him sleep. Staff D documented the daughter commented she couldn't get him to wake up or do anything. A facility form titled Employee Counseling form dated 9/21/24 for Staff A, CMA, listed the problem as a failure to report to the charge nurse due to lack of care for Resident #1. The form indicted they found Resident #1 lying in a urine-soaked bedding from head to toe at 6 PM. Staff A documented on the counseling form that Resident #1's daughter said to leave him around noon when they tried to re approach him to check and change him, so they left him be. On 11/26/24 at 11:42 AM, the Administrator reported the facility didn't have a policy related to urinary incontinence and the facility followed the standard of care. On 11/26/24 at 11:45 AM, the DON reported she expected the staff to check for incontinence after each meal, at HS, and on rounds during the night, approximately every 2 hrs. The DON reported Resident #1's daughter dictated his care and would help develop interventions. She stated if a resident refused to get out of bed or have cares completed, she expected the staff to check on the resident, reproach, and offer care again. An Appropriate Use of an Indwelling Catheter Policy, revised on 12/10/05, directed to not use an indwelling catheter unless there is valid medical justification. It will be discontinued as soon as clinically warranted and services will be provided to restore or improve normal bladder function after the removal of the catheter. A resident will receive appropriate care and services to prevent urinary tract infections while utilizing an indwelling catheter. The assessment for indwelling catheter use should include consideration of the risks and benefits (supra pubic or urethral); the potential for removal of the catheter; and consideration of complications resulting from the use of an indwelling catheter, such as, but not limited to: a. Symptoms of blockage of the catheter with associated bypassing of urine. b. Expulsion of the catheter. c. Pain d. Discomfort and bleeding. A Care Plan will be implemented to detail the treatment regime with the following information: a. Measurable objectives with time frames to be able to assess whether the objectives have been met. b. Interventions specific enough to outline treatment required including approaches to minimize risk of infection. Interventions may include, but not be limited to the following: i. Type of drainage device. ii. Tubing and bag care. iii. Catheter care. iv. Time frames for changing the catheter, tubing and bag. v. Type of anchoring device to prevent excessive tension on the catheter during transfers and care delivery. vi. Assessing and managing catheter related pain. An indwelling catheter for which continuing use is not medically justified will be discontinued as soon as clinically warranted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement treatment orders for pressure sores for 2 of 3 residents reviewed (Residents #307 and #39). In addition, the facility failed to identify a new skin injury for 1 of 3 residents (Resident #307). Resident #307 admitted to the facility on [DATE] with 2 skin injuries but the facility failed to get him treatment orders until 10/30/23. On 11/1/23 staff found Resident #307 with 2 additional areas of concern. Resident #39 had a chronic ulcer on his sacrum and saw a wound specialist on 10/25/23. The recommended treatment changes did not get implemented until 10/30/23. 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. 1. The Baseline Care Plan (BCP) dated 10/26/23, identified that Resident #307 required assistance from 2 persons with bed mobility, transfers and toilet use. He had a coccyx wound that measured 1.2 centimeters (cm) length x 1 cm width x 0.1 cm depth. In addition, he had a sore on his penis that measured 1 cm x 1 cm x 0.1 cm. The BCP described Resident #307 as very weak and admitted to the facility with hospice services. The Medical Diagnosis Sheet reviewed on 11/1/23 at 10:02 AM listed diagnoses of pneumonia and congestive heart failure. The Care Plan with a Target Date of 1/24/24 included the following Focuses: a. Resident #307 had a terminal prognosis related to heart failure. The Intervention directed the following: 1. Work with nursing staff to provide maximum comfort and wishes with him and/or his family. In addition, assure all staff knew of his requests. b. Resident #307 need assistance with his activities of daily living (ADL) related to sarcopenia (accelerated loss of muscle mass and function), his terminal status, and progressing overall weakness. The Interventions directed the following: 1. Resident #307 required total assistance with incontinence care. Please check and change him approximately every two hours. 2. and staff were to provide maximum comfort and to check and change him every 2 hours. 3. He required extensive assistance from 2 staff to turn and reposition. 4. Check his skin for redness and open areas. On 10/30/23 at 2:49 PM observed Resident #307 grimaced in pain as laid in bed on his back with a couple of his family members visiting. He said that the staff didn't come in very often to reposition him and he had difficulty moving around on his own. He said that he had a sore on his bottom that caused him some pain. Resident #307's October 2023 Medication and Treatment Administration Record (MAR/TAR) lacked orders to treat his wounds. On 10/31/23 at 12:57 PM the Hospice nurse said that they planned to have a wound specialist evaluate Resident #307. She did not know that he did not have any wound treatment orders. She expected the facility to call hospice for any orders that they needed. The on-going observation of Resident #307 on 10/31/23 revealed the following: a. 12:35 PM on his back in bed. b. 1:32 PM same position sleeping. c. 2:47 PM same position sleeping. d. 3:33 PM same position on his back. e. 4:12 PM same position on his back. On 11/1/23 at 7:50 AM, observed Staff L, Certified Medication Aide (CMA), and Staff O, Certified Nurse Aide (CNA), as they provided morning cares and cleaning for Resident #307. Staff L noted that he had two open areas on his coccyx where he initially only had one. Resident #307 had a red irritated spot on his right upper thigh where he had a sticker there to secure the urinary catheter. Staff O said that he had the sticker on his thigh since admission. The Skin Condition note dated 11/1/23 at 3:44 PM reflected a new abrasion to Resident #307's right inner thigh that measured 5 cm x 5 cm caused by the urinary catheter securement sticker. The document noted a reddened coccyx area but did not include measurements. On 11/2/23 at 10:52 AM the Director of Nursing (DON) said that Hospice should have provided orders for the treatments upon admission. She agreed that the spot on the thigh caused by the catheter sticker should have been found sooner. 2. Resident #39's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderately impaired cognition. Resident #39 required limited assistance from one person for bed mobility, transfers, dressing. The MDS included diagnoses of sepsis, muscle weakness, open wound of unspecified buttock, limitation due to disability, a stage 2 pressure ulcer of sacral region (base of the spine), and diabetes mellitus. On 10/31/23 at 8:14 AM, observed Resident #39 lying in bed with the wheelchair at the foot of the bed. He said that he had a sore on his bottom that was supposed to get changed daily but that did not happen every day. The Baseline Care Plan dated 9/15/23 at 1:36 PM, indicated that Resident #39 had an ulcer labeled as a stage III on his sacrum that measured 5 centimeters (cm) length x 5.5 cm width x 0.2 depth. The additional information detailed that he had a septic decubitus ulcer (bed sore) to his sacrum that he had for his last 3 hospitalizations. He had an above knee right amputation and could get himself into a wheelchair with good upper body strength. The Skin Condition Note dated 10/5/23 at 3:51 PM indicated Resident #39 had an area to his sacrum that measured 7 cm x 3 cm x 0.2 cm with a scant amount of serosanguineous drainage noted to bandage. The wound appeared beefy red. The wound looked as the size increased some, with some granulation, and some pain noted to area. He denied any complaints or needs at that time. Resident #39's October 2023 Medication and Treatment Administration Record (MAR/TAR) included an order dated 10/24/23 to apply Bactroban (an antibiotic ointment to treat skin infections) and cover with an Allevyn sacrum dressing daily. The Wound Care * Skin Integrity * Evaluation dated 10/25/23 reflected a change in treatment orders. The Treatment Intervention directed to clean the wound with normal saline. Then apply a collagen pad to the wound bed to promote autolytic debridement (slow, painless, removal of dead tissue through a moist environment that causes the body's natural enzymes to liquify). Cover with silicone bordered super absorbent dressing. Change dressing daily and as needed. On 10/31/23 at 2:56 PM the Wound Nurse Specialist said that she first saw Resident #307 on 10/26/23 and made some recommendations for treatment changes at that time. According to the electronic charting, the order did not get entered until 10/30/23 at 10:24 AM. On 11/1/23 at 9:15 AM, the Pharmacy Technician said that they received the new treatment order at the pharmacy on 10/30/23 at 10:50 AM. They delivered the supplies at 9:00 PM on 10/30/23. The Pressure Ulcer Risk Assessment and Documentation policy updated January 2011 instructed that to prevent pressure sores, interventions include to assist with repositioning immobile residents at a minimum of approximately every 2 hours. Observe for proper placement of tubing to reduce pressure risk and obtain treatment orders from the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment described her as independent with set up assistance with locomotion on and off the unit. The MDS indicated the she used a wheelchair. The Care Plan with a Target Date of 12/5/23 indicated that Resident #11 used a motorized wheelchair. The Interventions directed the following: a. Resident #11 understood that she must maintain the appropriate skill in the manipulation of an electric wheelchair to have the freedom of its use for independent locomotion. b. Resident #11 could go outside in the community with her electric wheelchair. The Incident Report Note dated 8/25/23 at 11:30 AM reflected that staff noted a burn to Resident #11's left mid back. Resident #11 reported that it happened over the weekend when she had too hot of a hot pack put on her back. The area measured 2.8 centimeters (cm) by 4 cm with part of the area open and not fluid filled. Resident #11 did complain of some discomfort to the burned area. The note listed preventative measures as educating the staff on heat packs and safety. Resident #11's clinical records lacked an order for a heat pad at the time of the incident. During an interview on 11/2/23 at 11:50 AM, Staff D, Licensed Practical Nurse (LPN) reported that Resident #11 no longer had a hot pack order. She verbalized they removed the order after the incident on 8/25/23. During an interview on 11/2/23 at 12:00 PM, Staff L, Certified Medication Aide (CMA), reported that the staff would heat the rice hot pack in the microwave in the therapy room. She explained that Resident #11 told the staff how long she wanted it heated. During an interview on 11/2/23 at 12:34 PM, Resident #11 reported that the nurse on the evening shift of 8/24/23 recommended a heat pad due to her being constipated. The staff heated the pad up and applied it to her back when she laid in the bed. Resident #11 reported that she felt burning on her back but could not remove the heat pad herself so she put on her call light. Due to it being supper time, the staff assisted residents to and from the dining room, so it took a long time for them to answer her call light. She reported that after the incident the staff never used a heat pad again for her. During an interview on 11/2/23 at 12:40 PM, the Director of Nursing (DON) reported she expected the staff to offer other options for pain relief and to not use a heat pad if they do not have an order for one. She reported that she remembered them talking about the incident at the safety meeting but they did not do a root cause analysis. She did not know which staff applied the heat pad because the facility did not investigate the incident further. She reported the facility put an intervention to no longer use a heat pad for residents. During an interview on 11/2/23 at 1:15 PM, Staff M, Certified Nurse Aide (CAN) reported that staff received education to heat the heat packs only in the microwave in the therapy room and wrap it in a towel, but they are no longer able to use heat pads. During an interview on 11/2/23 at 1:25 PM, Staff N, CMA, reported the staff received education to heat the heat pads only in the microwave in the therapy room and wrap it in a towel, but they are no longer able to use heat pads. An email communication provided from the facility on 11/2/23 at 4:00 PM documented on 9/18/23 to change to no hot pads in the facility and to get orders to discontinue the current orders for any residents who have an order for hot packs. 3. Resident #28's MDS assessment dated [DATE] identified a BIMS score of 3, indicating severely impaired cognition. Resident #11 required moderate assistance with transfers and supervision with ambulation. The MDS included diagnoses of dementia, type 2 diabetes, hypertension (high blood pressure), and malignant melanoma (a type of skin cancer). The Care Plan with a target date of 11/29/23 listed that Resident #28 had a risk for falls related to gait and balance problems. The included interventions indicated the following: a. Be sure that his call light is within reach and encourage him to use it for assistance as needed. b. Grip strips to be put in front of recliner. c. Ensure that he wore appropriate footwear when ambulating, transferring or mobilizing in his wheelchair. d. Leave Resident #28's door open at night. The Incident Report Note dated 10/12/23 at 9:15 PM reflected that staff found Resident #28 lying on the floor on his left side. He appeared alert, denied pain, and immediately requested to get up. He denied hitting his head when assessed. The completed assessment revealed vital signs within normal limits. The Incident Report Note dated 10/15/23 at 12:00 AM indicated that someone called the nurse to Resident #28's room. The nurse visualized Resident #28 lying on the floor in the bathroom doorway in front of his sink, positioned on his left side/buttock with walker in reach. Resident #28 reported that he lost his balance coming out of the bathroom. He had his shoes on and his floor appeared clean, dry, and without clutter. The Incident Report Note dated 10/21/23 at 5:27 AM labeled Late Entry reflected the staff found Resident #28 on the floor with his back against the wall. The CNA reported that she heard a thud that came from room C37 while at the desk. Resident #28 could not say what he did before his fall. He laid on the floor in front of his recliner, lying on his right arm, stomach, with his head, and feet toward his TV. He reported that he hit his head. The nurse completed the assessment with neurological checks (neuros) revealing a blood pressure of 170/79. His right outer leg had a skin tear and his head had some scrapes. The Incident Report Note dated 10/29/23 at 12:15 PM reflected that the CNA called the nurse to Resident #28's room. Upon arrival, the nurse observed Resident #28 on the floor, near his window, lying on his left side with his left arm behind his back. He could not say what he tried to do when he fell. The note described Resident #28 as having a decline in his cognition, had increased restlessness, confusion, agitation, and aggression in the previous few days. Resident #28 used as needed Ativan (antianxiety medication). The assessment revealed abrasions to his left forehead, the left side of his head, and a skin tear to his left cheek. During an interview on 10/30/23 at 1:00 PM, the DON reported that the facility does not do root cause analyses. The facility reviews the incident reports and discusses interventions to put into place at Quality Assurance (QA) and safety meetings. During an interview on 10/31/23 at 1:20 PM, the Administrator reported that any information collected for QA and safety is privileged information protected by law and he could not give that information out. 4. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognition. The MDS indicated that Resident #1 required extensive assistance of one person for bed mobility, transfers, ambulation, dressing, and personal hygiene, and extensive assistance of two persons for toilet use. The MDS included diagnoses of non-traumatic brain dysfunction, diabetes, Alzheimer's disease, moderate intellectual disabilities, and Down syndrome. Resident #1's Care Plan revealed that resident is to transfer with one assist using a gait belt and four wheeled walker. On 10/30/23 at 2:00 PM, observed Resident #1 sitting in a chair at the nurses' station. Staff G, CNA, and Staff J, CNA, approached him, then assisted him to stand by putting their arms under his armpits and pulled up on the belt loops of his pants. No observation of the CNAs using a gait belt with Resident #1 for his transfer. On 11/1/23 at 1:30 PM, Staff J stated that she knew she should have used a gait belt to assist Resident #1 to stand. On 11/2/23 at 2:25 PM, the DON said that she expected the CNA's to use a gait belt to transfer the resident. Based on observation, interview, and record review the facility failed to keep residents safe from accidents and hazards for 4 of 4 residents reviewed (Resident #7, #28, #1, and #11). Staff failed to use a gait belt or ensure proper footwear use when transferring Resident #7. Resident #7 fell on her way to the bathroom and sustained a major injury. After Resident #28 fell, the staff failed to complete neurological assessments. During an observation of a transfer of Resident #1, staff failed to use a gait belt. After Resident #11 sustained a foot injury while off campus, the facility failed to complete an incident report. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status score (BIMS) of 12, indicating moderately impaired cognition. She required extensive assistance from 1 person for bed mobility, transfers, walking, dressing and toilet use. She used a walker and wheelchair for mobility. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. She required extensive assistance from 2 persons for bed mobility, transfers, dressing, and toilet use. The Care Plan with a target date of 11/28/23 included the following Focuses a. Resident #7 had a risk for falls related to deconditioning and bilateral lower extremity weakness. The Interventions directed the following: - Please ensure that Resident #7 wore appropriate footwear when she walked, transferred, or moved in her wheelchair. b. Resident #7 required assistance with her activities of daily living (ADLs) related to weakness, fatigue, and a fracture. - 2/17/23: She needed limited assistance from 1 staff with toilet needs, revised 9/17/23. - 9/17/23: She needed extensive assistance from 2 staff with toilet needs. The Incident Report provided by an anonymous source dated 8/31/23 at 4:35 PM lacked an incident description, an immediate action, and indicated that Resident #7 did not go to the hospital. Resident #7 had a pain level of 10 out of 10 on the pain scale, indicating severe pain with a mental status of oriented to person, place, time, and situation. The report indicate that Resident #7 did not have injuries observed following the incident. The Predisposing Factors reflected the following: a. Environmental: Other (Describe) b. Physiological: Gait imbalance c. Situational: Ambulating with assistance and using a wheeled walker. d. Other info listed oxygen tubing. The facility's report labeled Investigation, Summary and Findings, dated 9/1/23 showed that Resident #7 had a BIMS score of 12, indicating she is alert and oriented. On August 31 at approximately 4:35 PM, Staff I, Certified Nurse Aide (CNA), walked with Resident #7 to the bathroom. Resident #7 fell, landing on her right knee. She complained of severe pain to her right knee. Staff Q, Registered Nurse (RN), called for an emergency transfer to the hospital. While at the hospital, they found that Resident #7 had a distal femoral periprosthetic fracture (broken bone that occurs around an implants following a bone replacement) to her right leg. Staff Q reported that she just finished completing a treatment for Resident #7 and putting the supplies away. At that time, Resident #7 stood up and started walking to the bathroom. When she saw this, Staff Q called for Staff I to help Resident #7 to the bathroom due to her being nearby at the time. Staff I reported that she did not have time to apply a gait belt to Resident #7 because she already started walking hurriedly towards the bathroom. Staff I said that as Resident #7 reached for the bathroom light, her legs gave out and she fell on her knee. Staff Q reported that she could not complete range of motion (ROM) due to the amount of pain Resident #7 had. The reported reflected that Resident #7 could use the toilet and transfer independently in her room with her walker but, required limited assistance from one staff member to assist with her toilet needs. The Care Plan included the intervention for Resident #7 to wear appropriate footwear. At the time of her fall, Resident #7 did wear appropriate footwear. The handwritten statement received by the facility on 9/7/23 from Staff I indicated that she used the gait belt when transferring or assisting a resident with ambulating. For the incident with Resident #7, she did not have the opportunity to put a gait belt on her, due to her already standing and walking to the bathroom. Instead, she continued to help Resident #7 balance by holding her arm while she walked without difficulty. Staff I added that she felt the gait belt would not have prevented the fall from happening. On 10/30/23 at 12:30 PM, observed staff prepare to transfer Resident #7 from her bed to the bathroom with the use of a sit to stand lift. Resident #7 said that she remembered some things about the fall and thought that she may have tripped on the transition going to the bathroom. Resident #7's family member stated that a few days before that fall, Resident #7 got lowered to the ground. They alerted the staff that her legs did not appear as strong as before and that she needed extensive assistance. On 10/30/23 at 4:18 PM, Staff I said that on the afternoon when Resident #7 fell, she did not put on her call light for help. Staff I walked down the hall and noted the nurse just left Resident #7's room, the nurse stepped out and told Staff I that Resident #7 needed to use the restroom. When Staff I entered the room, she saw Resident #7 standing with her walker, heading towards the bathroom. She said she didn't have time to put on the gait belt. I saw her already standing up. I couldn't catch her. She reported that Resident #7 already started to fall when she entered the room. She maintained that Resident #7 wore shoes and stockings. Staff I said that she ran to catch Resident #7 but did not have time to put a gait belt on. Staff I reported it as unusual for Resident #7 to get up on her own, she usually waited. Resident #7 never refused to wear a gait belt. Staff I said that when the paramedics arrived, they used the full-body mechanical lift to get her off the floor. She said that Resident #7 wore her oxygen while ambulating and it dragged behind her during the fall, Staff I did not think that she tripped on the tubing. The Emergency Services Report dated 8/31/23 at 4:53 PM indicated that the Emergency Medical Services (EMS) arrived to find Resident #7 leaning on a pillow on her right side. The staff reported that Resident #7 walked with only socks to the bathroom when she slipped and landed on her right knee. Resident #7 appeared stuck between the door and the toilet in a very small restroom. They applied a gait belt to Resident #7 and a blanket beneath her arms to assist her to stand on her good leg. Resident #7 rated her pain at a 10 with movement but denied pain with movement. On 10/31/23 at 10:45 AM Staff Q said that around supper time she began providing wound treatment for Resident #7. Resident #7 stood by her bed as she did the wound treatment on her coccyx. Resident #7 told her then that she needed to use the restroom. Staff Q said that she still had a lot of the treatment left to complete. Resident #7 sat down on the bed as Staff Q stepped out in the hallway and asked Staff I to take her to the bathroom. Staff Q saw Resident #7 start to stand with her walker, then left the room when Staff I started to walk her toward the bathroom. Staff I did not put on a gait belt. Staff Q got a little way down the hallway when she heard a thump. She did not know for sure what Resident #7 had on her feet, she thought it was either non-skids stockings, shoes, or slippers. When the paramedics came in they put on a gait belt, assisted her to stand on her good leg and pivoted her to the cot. On 11/2/23 at 10:52 AM when asked if the oxygen tubing could have caused the fall, the Administrator reported that Resident #7 reported 4 different things that may have caused the fall, indicating that she had confusion. He said that he did not think they could have done anything differently to prevent the fall. On 11/6/23 at 9:38 AM the Paramedic that picked up Resident #7 on 8/31/23 said that she remembered Resident #7 wore socks, not gripper socks, and no shoes. She remembered this because when getting Resident #7 off the floor, she put her foot up against her foot to help support her and noticed the socks. They put a gait belt on her and wrapped her with a blanket to use as a gait belt as well. She said that they had her put weight on her left leg and pivoted her to the cot. She reported the bathroom as a very tight and small making it difficult to maneuver her off the floor. The Transfer/Gait Belts/Ambulation and Use of Safety Straps/Belts policy reviewed November 2008 directed the staff to use gait belts on residents who required assistance with transfers and /or ambulation when not using a mechanical lifting devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure safety interventions were followed during a transfer of 1 out of 3 residents reviewed (Resident #2). Resident #2 was transferred by 1 staff instead of 2 using an EZ Stand (lift for transfers) which resulted in the resident sliding down from the stand. Follow up after this incident was not sufficient from the covering nurse to ensure resident was assessed, to prevent future falls, and to report the incident to the oncoming shift so they would have knowledge about this incident. Resident was diagnosed the following day with a fractured leg. This resident was transferred with 1 staff and the EZ stand again at least three times after this incident and prior to being sent out to the hospital the following day with the fracture. The facility reported a census of 52. Findings include: A Minimum Data Set, dated [DATE], documented that Resident #2's diagnoses included congestive heart failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). This resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated her cognition was intact. This resident required extensive assist of 2 for transfers. A Care Plan with a focus area revised on 4/11/16, documented that Resident #2 needed assistance with her ADL's (activities of daily living) related to limited ROM (range of motion). An intervention created on 4/11/22 directed staff that Resident #2 needed extensive assistance of 2 staff and EZ stand for all transfers. It documented that on 2/14/23 the transfer was revised to direct staff that Resident #2 needed extensive assistance of 2 staff and a Hoyer lift for all transfers. An Incident Report dated 2/12/23 at 6:42 a.m., and documented as a late entry for 2/11/23 at 4:10 a.m., documented the following: -Describe Situation: Staff A, Certified Nurse Aide, (CNA) summoned Staff B, Registered Nurse (RN) to Resident #2's room where Staff A was transferring Resident #2 via the EZ-Stand from the bed to the wheelchair. As Staff A was performing the transfer Staff A noted that the resident was starting to slide out of the sling and lower towards the floor. Staff B arrived and Resident #2 was still standing up right with the EZ stand but knees were bending and the resident was chicken winging her bilateral arms slowly out of the EZ stand. Staff B was able to slide behind this resident before her bilateral buttocks came to a rest on the floor, slowly as Staff A lowered Resident #2 to that position for safety. Staff B remained behind resident with Staff B's leg pressed up firmly against this resident's back serving as a backrest to a chair for the resident as Staff A retrieved the hoyer lift (a lift that does not require standing) to be used to assist Resident #2 from sitting position on the floor into her wheelchair. -The Assessment of Resident Including ROM and pain: documented that Resident #2 complained of discomfort to bilateral lower extremities as she was resting on the floor in a sitting position due to Resident #2 sitting with her left lower extremity bent to the left as she was positioned on the floor during the landing and there was a very limited amount of space to do transfer and it was too cramped of an area to unbend her knee as she was lowered to the floor. -Describe Any Injury Noted: none visible, Resident #2 only complained of pain to bent knee but after Resident #2 was assisted to wheelchair via Hoyer and assist of 3 staff and was able to straighten leg out better, pain significantly subsided. -List Any Treatment Provided: none -List Relevant Interventions That Were in Place At The Time of Incident: (left blank) -Preliminary Recommendations, If any, for consideration as further preventative measures: Assist with 2 staff with Hoyer ONLY! For resident and staff safety. Physician was notified This Incident Report was signed by Staff B. A 24 hour follow up to incident report dated 2/12/23 at 4:38 a.m., documented the following: -Describe the Incident Being Followed Up on:: staff assist fall lowered to floor via EZ stand. -Document New Interventions Placed following the incident: Resident #2 to be assist X 2 with hoyer at all times for transfers. -Document Any Further Notifications Regarding Incident: (no entry) -Document any New Injuries discovered after the initial assessment that are a Result of Incident:: None visible or reported by resident. A Communication with Physician, progress note, dated 2/12/23 at 1:18 p.m., documented that this nurse (Staff E, Licensed Practical Nurse (LPN)) was notified that Resident #2 fell out of the EZ stand yesterday a.m. Staff E was called STAT (immediately) to this resident's room this a.m. at 5:30 to help get resident back in her wheelchair. Assist X 4 was needed with the EZ stand to get resident scooted back in her wheelchair. This nurse informed staff to only transfer this resident with a hoyer. This resident informed of this and explained why. Resident #2 then complained of left knee pain and rated it at an 8 out of 10 (with 10 being the worst pain) and described it as an aching pain with movement. Resident #2 denied pain with movement. This resident denied pain at rest. Scheduled and PRN (as needed) acetaminophen given with little relief. A bruise and crease mark noted to lower left knee measuring 5 cm X 4.5 cm. The bruise was brown in color. The provider was notified and a new order to get a STAT X-ray of the left knee was obtained. Message was left for the daughter and skin sheet was updated. This Resident was aware of the orders. A Transfer to Hospital Summary, progress note, dated 2/12/23 at 5:03 p.m., documented the following: Reason for transfer: Recent fall, suspected femur (thigh bone) fracture post X-ray. A Diagnostic Test progress note documented as a late entry on 2/12/23 at 9:30 p.m., documented that X-ray results were received. Left knee findings included a comminuted oblique fracture of the distal left femoral metaphysis. (a fracture of the thigh bone close to the knee) The distal fracture component is displaced and angulated posteriorly and medially (the fracture is angled off the bone). Moderate to severe tricompartmental degenerative diagnosis (knee arthritis). Diffuse osteopenia (decrease in bone density). A hospital Final Report dictated or performed on 2/15/23, documented that Resident #2's injury was an acute, comminuted displaced distal left femoral metadiaphyseal (growth plate at the end of a long bone fracture) fracture. It documented that procedure done was an ORIF (Open Reduction Internal Fixation) of left femur on 2/13/23. A Therapy Screen done on 2/14/23 documented that Resident #2 was now non-weight bearing on Left lower extremity and unable to use EZ stand. It documented that Resident #2 would now require a hoyer lift to complete safe transfers. On 4/12/23 at 11:14 a.m., Resident #2 was up in her wheelchair with a Hoyer sling underneath her. She stated she did not remember if there were 1 or 2 staff that normally transferred her with a stand lift (EZ Stand). She stated the night that she fell, there were 2 staff there. Resident #2 stated she really didn't know why she fell. Resident #2 stated that they use the swing lift (Hoyer) on her now. She stated she had to go to the hospital after her fall. On 4/12/23 at 12:56 p.m., Resident stated she wanted to go back to bed to get cleaned up. Staff C, CNA called the Director of Nursing (DON) to come to room. The DON entered room and stood by the window to watch. Resident #2 stated I'm scared of this thing (referring to the Hoyer lift). The DON responded to Resident #2 to just hug yourself. Resident #2 stated don't let me fall and I've fallen too many times now. Staff C and the Certified Occupational Therapy Aide (COTA) lifted resident up with the Hoyer lift from her wheelchair and turned the resident toward the bed. Resident stated I don't like this. They had to turn the resident around in the Hoyer (so that her feet would be at the end of the bed and her head at the top of the bed), then lowered her onto her bariatric bed. On 4/13/23 at 11:22 a.m., Staff A stated she was working night shift and this resident was to get up early before the day shift arrived. Staff A stated this resident was care planned to wake up early as that is what this resident wanted. Staff A stated that Resident #2 usually gets up by using the EZ Stand. They then would transfer her to a commode in the room as the EZ Stand they used to transfer this resident was a large one and would not fit into the bathroom. Staff A stated she had gotten Resident #2 up to the commode the morning of her fall and then she was transferring Resident #2 from the commode to the chair. Staff A stated that when she was turning the EZ Stand with Resident #2 in it from the commode to the chair, Resident #2 started saying put me down, put me down. Staff A stated Resident #2 was not above the chair when she was saying this. Staff A stated she called the nurse for help on the walkie. The nurse came before completely putting this resident down. Staff A stated that Resident #2 was close to the chair but not close enough for her to sit. Staff A stated that Staff B came right away as Staff A was not very far away. Staff A stated that Staff B was trying to hold her. Staff A stated she said she could let the lift down and that Staff B was not able to hold her. Staff A then let the lift down slowly. Staff A stated Resident #2 was sitting on the floor on top of Staff B's leg. Staff A stated she then grabbed the hoyer lift and then lifted Resident #2 to the bed. Staff A stated that Resident #2 didn't complain of pain. Staff A stated they then transferred Resident #2 from the bed to the wheelchair using the hoyer lift. She stated Resident #2 did not like the hoyer lift. Staff A did not remember Resident #2 complaining of pain. Staff A stated that she and Staff B asked Resident #2 if she had pain and Resident #2 said no, she didn't have any pain. When asked why she lifted this resident by herself using the EZ Stand, Staff A stated the care plan said 1-2 for EZ Stand. When the care plan was read to Staff A, Staff A stated she thought the care plan stated 1 person. Staff A stated she was trained to transfer by herself using an EZ Stand in school and at the facility. Staff A stated she did not remember who trained her at the facility. Staff A stated the Care Plan that was read to her directed to use 2 people with the EZ stand transfer for Resident #2. Staff A stated she looks at the care plan in the computer and that staff have tablets and Kardex in the computer that they can find anything they need to know about a resident. Staff A stated she did not know that Resident #2 was a 2 person lift, and stated she had been transferring Resident #2 by herself without a second person. On 4/13/23 at 11:50 a.m., the Administrator and the Nurse Consultant were asked about care plan directing staff to use extensive assist of 2 with EZ stand for transfers. The Administrator stated he did not know if he followed up with sister regarding need for a 2nd person for the transfer. The Administrator stated he would look at his notes to see if the conversation happened. The Nurse Consultant looked up the Care Plan and concurred that at the time of the fall the Care Plan directed staff to use an extensive assist of 2 with the EZ Stand for Resident #2's transfers. When the Administrator and Nurse Consultant were told that there was a concern with this, they both nodded in understanding. When told a concern would be submitted to the office, they nodded in understanding. On 4/13/23 at 2:30 p.m., the Administrator stated that he does not know all of the resident's Care Plans and depends on the DON to provide that information. On 4/13/23 at 3:29 p.m., the DON stated she did not know that Staff A had transferred Resident #2 by herself. The DON stated that when she came in on Monday (2/13/23), she was told that Resident #2 had slipped out of the EZ stand and staff had just sat her down. The DON stated she had talked to Staff A about it and the Administrator also talked to Staff A about it. The DON stated that Staff A did not tell the DON that Staff A had transferred Resident #2 by herself. She stated then Staff A talked with the Administrator. The DON stated her expectations were for the CNAs to follow what the Care Plan says and to know how to access the POC (Point Of Care(care plan interventions on Kardex/where CNAs document when they complete interventions)). The DON stated she had not talked with Staff A after her initial conversation with Staff A following the incident. On 4/13/23 at 6:30 p.m., Staff B, RN, stated she was walking down the hall Resident #2 lives on at the time of the incident, so she was right outside of the room. Staff B noticed that Resident #2 was probably about ½ way to the floor sliding out of the EZ Stand. Staff B went to the side of Resident #2 and helped ease her the rest of the way down to the floor. Staff B stated that Resident #2's back was against Staff B's leg and Resident #2 was kind of propped up against Staff B. Staff B stated that Staff A then went and got the Hoyer lift. Staff B believed the Hoyer lift was out in the hall. Staff B stated another CNA came into the room to help with the transfer off of the floor but was not sure which CNA helped. The other CNA helped maneuver Resident #2 and transferred this resident with the Hoyer to her to the wheelchair. Staff B stated she did not remember if they lifted Resident #2 to the bed first or to her wheelchair. Staff B stated they may have put her in the bed, but she honestly could not remember. Staff B stated she then did an assessment. Staff B stated this resident's vital signs were within normal limits. Staff B stated Resident #2 was not complaining of pain then or the rest of the day, until she complained of pain on the following day. When asked about why her documentation read that Resident #2 had pain while Resident #2 was sitting on the floor, Staff B stated that maybe Resident #2 did say that, but once they got her up, Resident #2 was better. Staff B added, that now that she was thinking about it they were kind of in tight quarters and Resident #2's legs were kind of bent. When asked if Staff B had checked Resident #2's ROM, She stated she did. Staff B stated she moved Resident #2's legs as much as Staff B could move them. Staff B stated that Resident #2 was a larger woman and that Resident #2 did not do a lot of bending. When asked how this resident transferred, Staff B stated she believed Resident #2 was supposed to be assist of 2. Staff B stated she talked with Staff A about the transfer after they got Resident #2 all situated. Staff B stated she asked Staff A wasn't Resident #2 an assist of 2 and Staff A answered she didn't know that. Staff B stated she thought everyone knew that. Staff B stated she thought Resident #2 was care planned (to use an EZ Stand lift with assist of 2 staff). Staff B stated she hadn't witnessed any staff prior to this that were transferring with using just one person. Staff B stated that staff have access to see what assistance level each resident needed, so Staff B stated she would think they would all know. Staff B stated that for safety Resident #2 should have always been a 2 person transfer with the EZ Stand. Staff B stated if she were to transfer Resident #2, Staff B would have always used 2 staff. Staff B stated she thought with Resident #2's size that definitely Resident #2 was more of safety risk for sure. Staff B stated that Resident #2 really didn't stand all that well to begin with. Staff B said she had not helped with transfers for Resident #2 before but had walked in before to do something with Resident #2's roommate and have seen the girls (staff CNAs) taking Resident #1 to the bathroom. Staff B stated the girls have always said that taking her from the bed to the bathroom was difficult to push Resident #2 in the EZ Stand and with her weight and all, they always used 2. Staff B stated she had never seen anyone transferring Resident #2 alone. Staff B stated Resident #2 was not one to complain at all about pain. Staff B stated she felt that Resident #2's weight and all and going down in the EZ Stand probably caused her leg to break. When asked why Staff B thought this, she stated that Resident #2 has had a broken leg in the past. Staff B said that Resident #2's weight going down on that leg was probably what caused the fracture. Staff B stated she was surprised that they did operate on Resident #2's leg because Staff B did not think Resident #2 would have been a surgical candidate. Resident #2 guessed that Resident #2 had low bone density. On 4/17/23 at 1:08 p.m., Staff D, CNA, stated she did not know about Resident #2's fall when she transferred Resident #2. Staff D stated that when she transferred Resident #2, Resident #2 complained of her knee and her leg hurting. Staff D did not know what day this resident was complaining of pain with transfer, if it was the day she went to the hospital or the day before. Staff D stated she told the nurse and the nurse came to look at it. Staff D didn't know which nurse she told. Resident #2's knee was red and was starting to bruise. Staff D stated she transferred Resident #2 once by herself that's when Resident #2 complained and once with someone else on the day the resident complained of pain. Staff D stated she did not know what the care plan directed. Staff D stated she tried to get help whenever she could because Resident #2 was kind of heavy and the transfer could hurt Staff D. Staff D stated she did know how to look up things in the care plan. Staff D reiterated she didn't know that this resident was a 2 person transfer. Staff D stated that when she was trained in January, she was told that Resident #2 was a one person transfer. Staff D did not remember who trained her as she was kind of just thrown in to it. Staff D thought she had maybe a couple of days of training. Staff D stated they have to use the laptop or the computer to get to the care plan. Staff D stated they use the facilities phones to get to the Kardex, and that was what they carry because it has all of their charting on it as well as the call light system. When Staff D was asked to pull up this resident's Kardex on her phone and Staff D did. Staff D pulled up Resident #2's Kardex and stated that it documented I need extensive assist of 2 with a hoyer for all transfers. On 4/17/23 at 1:49 p.m., the DON stated her expectation for follow up after a fall would be to assess immediately after the fall and then again 24 hours after a fall, unless the resident had hit their head, then neuros (neurological assessment) need to be done. When repeated back to DON, that the expectation for nurse assessment and follow up would be that unless the resident hit their head, the nurses did not need to assess a resident again after a fall until 24 hours after the fall, she stated that was true, unless they hit their head, or there was pain, or other extenuating circumstance that would require closer evaluation. On 4/17/23 at 1:57 p.m., Staff E, Licensed Practical Nurse (LPN), stated she did not know that Resident #2 had slipped in the EZ Stand. The nurse (Staff B) had not told Staff E that Resident #2 had fallen the day before. Staff E stated staff were struggling with Resident #2 using the EZ Stand about 5:30 a.m., on 2/12/23. Staff E stated that she had arrived to the facility at 5:00 a.m. that morning. Staff E stated that Staff H, CNA was transferring Resident #2 by herself. Staff E told Staff H that she needed to use 2 staff for Resident #2's transfers. Staff E stated she did not know why people don't know that Resident #2 was an assist of 2 with all transfers. Staff E stated that staff can look up Resident #2's transfer needs in her care plan as well. Staff E stated that Staff H responded that she didn't know that Resident #2 required assist of 2 for transfers. Staff E stated she was very upset that Staff B had not told her that this incident had happened the day before. Staff E stated that Staff B told her she did not think it was a fall. Staff E told her that it was an incident. That any time a resident goes from a higher elevation to a lower elevation and it is not purposeful, it was considered a fall. Staff E stated that Staff B had to do a late entry for the fall after they had this discussion on 2/12/23, after Staff E found out that this resident had a fall in the EZ stand. Staff E stated that Resident #2 was not expressing a lot of signs of pain, which is crazy. Staff E stated because Resident #2 was bruising and if you just moved her a little, you can tell she had signs of pain. Staff E stated Resident #2 was having facial grimacing, but verbally she would say she was fine. Staff E stated that Resident #2 was not really a complainer. Staff E stated that Resident #2 liked to be told everything staff are doing, because she finds things scary. Staff E stated she changed Resident #2 to a hoyer lift and Resident #2 wanted Staff E there in the room for a couple of transfers. Staff E stated that the slip in the EZ stand the day prior was an incident even if you go from one level to another, you have to report it. And chart on it of course. Staff E stated the morning of 2/12/23 they got Resident #2 into her bed. Staff E stated she could tell Resident #2 was in pain. Staff E stated Resident #2 had a bruise on her left knee. Staff E stated they ordered a STAT X-ray too. Staff E stated the X-ray tech said leave her in bed as he saw there was a fracture. Staff E stated they did not know if Resident #2 would be a surgical candidate, but Staff E stated she called the doctor and the doctor wanted Resident #2 sent out. Staff E stated what should have happened was when there's an observed fall the nurse does a 24 hour and then a week follow up assessment. Staff E stated that the fall should be documented in Risk Management and the nurse (Staff B) should have verbally told Staff E (the oncoming shift nurse). Staff E stated that with each fall the nurses are to notify whoever is on call. Staff E doubted that Staff B notified the on call. Staff E stated that Staff B put in an incident report the other day. Staff E stated that Resident #2 was probably transferred 3 or 4 times after her 'fall' that morning and that Staff E wasn't told that Resident #2 was in pain prior to that. 4/18/23 at 11:16 a.m., Staff H, contact attempted, voicemail left and text sent requesting a call back. A Southfield Wellness Community Documentation Survey Report (CNA documentation of work done) for 2/2023 printed on 4/13/23, revealed that the 8 of the 18 transfers for Resident #2 were documented from 2/1/23 to 2/12/23, were documented as 1 person transfers. Staff A's initials were not on this document. Staff D signed that she transferred Resident #2 on 2/11/23 twice by herself at 10:23 a.m. and at 4:38 p.m. Staff D signed that she transferred Resident #2 once on 2/12/23 at 11:58 a.m. with a second person. Staff F, Staff K, and Staff L had all signed that they had transferred the resident by themselves during the time period above (2/1/23 to 2/12/23). Staff L's initials were not on this document the morning of 2/12/23 when Staff L stated she transferred this resident by herself with the EZ stand. 4/18/23 at 11:32 a.m., Staff F, CNA, stated they were told to transfer Resident #2 using a 2 person assist with the EZ stand. Staff F stated she wouldn't feel comfortable transferring her without a second person. Staff F stated she would not have transferred Resident #2 by herself especially because Resident #2 is larger and Staff F would not feel comfortable at all transferring her alone. When asked about signing that she did a limited assist transfer by herself, she stated that she started in November and really doesn't know all of the residents, so she probably got this resident mixed up with another resident. Staff F added that if she charted it was a limited assist of 1 then she was probably charting about doing part of Resident #2's care and charted in the wrong place. On 4/18/23 at 2:00 p.m., Staff K, CNA, stated that Resident #2 had always been a 2 assist EZ Stand transfer. Staff K stated that at first it was a regular EZ Stand and then it was changed to the larger EZ Stand. When asked about her documenting that she transferred Resident #2 by herself, Staff K stated that she had transferred Resident #2 once or twice because no one would come to help her. Staff K stated she would walkie (radio) others for help and go looking for help, but because no one was coming and it was taking so long, Staff K just went ahead and transferred Resident #2. On 4/19/23 at 9:52 a.m., Staff L, CNA, stated that she transferred Resident #2 by herself. Staff L stated she did not know Resident #2 was a 2 person EZ stand transfer. Staff E stated that direction might be in the Kardex or Resident #2's care plan but Staff L was not trained on how to look the information up. Staff E stated nobody had told her that Resident #2 was a 2 person EZ stand. Staff L stated that every place she had worked prior to this facility EZ stand transfers had been done by 1 person. Staff L stated she was never told anything until the incident that Staff L had with the resident. Staff L stated that she talked with other staff and they told Staff L that when COVID 19 hit the facility changed their policy to 1 person EZ stand transfers. Staff L stated that it would have been nice to know that Resident #2 had fallen the day before. Staff E stated she wasn't informed of the fall until after the fact. When asked if she knew why the information wasn't shared, Staff L stated that from her understanding there was a bunch of miscommunication about it, they said she didn't fall, but Resident #2 told Staff L that she had fallen and Resident #2's roommate said the same thing. Staff L stated she had an incident the day after the fall, on the morning of 2/12/23 around 5:00 a.m Staff L stated she transferred Resident #2 by herself and Resident #2 did not fall, but Staff L could not get this resident far enough back in to the wheelchair, so Staff L called for help. Staff L stated when she called for help the EZ stand was still attached to Resident #2. Staff L stated Resident #2 complained of pain during the transfer. Staff L asked Resident #2 what was wrong, and Resident #2 stated it was her leg. Staff L stated later on Resident #2 said that the fall had hurt her the day before. When asked if she was talked to the day she transferred Resident #2 to her wheelchair, Staff L stated the charge nurse didn't tell Staff L that this resident was a 2 person assist with EZ stand. Staff L stated the DON called Staff L after this. Staff L stated she asked the DON if this resident was a 2 person EZ stand transfer and the DON said this resident was a 2 person assist with EZ stand. Staff L stated she then asked the DON what to do if they didn't have enough help and the DON answered that Staff L would need to do the transfer by herself. Staff L stated that when she transferred Resident #2 the morning that she could not get this resident far enough back in her wheelchair seat, the night shift nurse (Staff B) was still there and Staff B and Staff E were going back and forth about why the fall the night before wasn't reported. Staff L stated that it was a big deal. Staff L stated that Staff B said that Resident #2 had not fallen. Staff L stated that this resident said she had fallen and Staff E said that the resident had fallen and they had to use a hoyer to get this resident off of the ground. Staff L stated that this resident told her that her leg did hurt and that her leg was stuck under the bed the day before, Staff L stated that Resident #2 was well aware of what was going on. Staff L stated the staff have had no training regarding EZ stand transfers after these incidents occurred On 4/12/23 at 11:46 a.m., Staff G, CNA stated she has worked at the facility since January. She stated she looks at point of care for residents ADL and transfer needs. She stated it will say how a resident is to be transferred. She stated that an EZ stand can be run by 1 or 2 staff. She stated a hoyer lift always takes 2 staff and sometimes 3. When asked about Resident #2 and if she had transferred her with an EZ stand prior to her fall, Staff G stated she had but she would always use 2 staff as the EZ stand was a wide one and she would not be comfortable with transferring Resident #2 by herself. Staff G stated the lift could get wobbly and possibly tip. Staff G stated that she also would use 3 people when using the Hoyer lift on Resident #2 now, depending on the day. This CNA stated she had not been trained at this facility on how to transfer with the EZ Stand by herself. She stated she had education on this at another facility prior to coming to this facility. On 4/12/23 at 11:50 a.m., Staff H, CNA stated that it was on the computer where we find what a resident's plan of care was. Staff H stated that the nurse would also let the CNA's know if there were any changes. Staff H stated that the EZ stands normally require 2 staff because a lot of the residents do the chicken wing thing with their arms, so they have 2 people even if it would say 1 or 2 people in the care plan. Staff H stated she had not worked with Resident #2 as usually Staff H worked in the front of the building. On 4/12/23 at 12:00 p.m., Staff I, CNA, stated there should always be 2 staff with EZ stands. There may be someone that says 1 or 2 but Staff I preferred 2. Staff I stated that sometimes they may need 3 to transfer using a Hoyer lift. Staff I stated she thought there was 1 resident who was care planned as a 1 assist EZ Stand, she stated even then she always used 2. Staff I stated that she received no official training on a 1 person EZ Stand Transfer and added that Hoyer lifts are always at least 2 assist. A Fall Risk Assessment & Intervention Policy revised on 2/2000, documented that residents will be assessed upon admission, re-admission, and change in condition for potential risk factors associated with falls. Initial interventions specific to the resident will be implemented at the time of the assessment. Procedure: 1. The assigned nurse will complete the admission / readmission Fall Risk Assessment and Interventions tool on new admissions, readmissions, and residents experiencing a significant change in condition. a. If the facility prefers, they may use the Falls Risk Assessment from Dextrosity instead of the admission / readmission Fall Risk Assessment and Interventions tool. 2. Determine the risk factors placing the resident at risk for falls by highlighting or circling those factors (left side of admission / readmission Fall Risk Assessment and Interventions tool). 3. Determine what interventions could be used, specific to the resident, and highlight or circle the appropriate interventions - and /or write additional interventions (right side of admission / readmission Fall Risk Assessment and Interventions tool). 4. The nurse completing the falls assessment will be responsible to communicate interventions to appropriate staff. 5. Risk factors and interventions identified on the falls assessment tool should be carried over - and used - to facilitate development of the resident's plan of care. (The tool may be added as a part of the care plan). 6. Elicit ideas to reduce the likelihood of falls from the resident (if capable), family members, therapies, physician, and interdisciplinary staff. 7. Orthostatic blood pressure should be taken, if possible, following a fall to determine whether the fall could be related to dizziness associated with a sudden drop in blood pressure with position changes. a. Refer to the Orthostatic Hypotension policy for guidelines related to protocol for taking orthostatic blood pressures. 8. Should the resident experience a fall, an Incident Report and Quality Assurance Investigation form will be completed. a. Each fall will be assessed to try to determine the cause (may need to reenact the fall by taking a team and actually going to the site where the fall occurred). b. The care plan must be reviewed with each occurrence and new/different approaches added relative to the assessed cause of the fall.