**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), whose Plans of Care indicated that they required the physical assistance of two staff members with transfers and/or bed mobility, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in their Plans of Care while meeting his/her care needs. 1) On 08/05/24, Certified Nurse Aide (CNA) #2 provided care to Resident #2, who was in bed, without getting assistance from another staff member, CNA #2 left Resident #2 lying on his/her right side in bed, walked to the bathroom, heard a loud bang and found Resident #2 lying on the floor beside his/her bed on his/her left side. Resident #2 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fractured left hip which required surgical intervention to repair. 2) On 08/03/24, CNA #1 transferred Resident #1 from his/her wheelchair into bed, without getting assistance from another staff member. Resident #1 complained of left ankle pain after the transfer, and was diagnosed by an orthopedic physician with a second or third degree (partial to complete tear of the ankle ligament) left ankle lateral sprain which required a brace for comfort. Findings include: Review of the Facility's Policy, titled Care Plans Policy, dated as revised May 2017, indicated the following: -an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident; -the Facility's Care Planning/Interdisciplinary Team (IDT) in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to maintain; -each resident comprehensive care plan incorporates identified problem areas, incorporates risk factors, builds on resident's strengths, identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status, enhance the optimal functioning of the resident, reflect currently recognized standards of practice; -care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes; -assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes; -the Care Planning/IDT team is responsible for the review and updating of care plans when there has been a significant change in the resident's conditions, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly. Review of the Facility's Policy, titled Resident ADL Guide/[NAME], dated as reviewed December 2023, indicated the following: -CNA's are provided with a complete and updated reference source for resident care needs upon admission and throughout length of stay; -upon admission, the Resident ADL Guide [NAME] is to be completed by the Admitting Nurse to enter into Point of Care (POC) in Net Solutions (Electronic Medical Record); -ADL [NAME] are to be assigned in POC for designated CNA assignments; -CNA's are to check their residents [NAME] in POC prior to starting their assignment and refer to [NAME] in POC periodically throughout their assigned shift; -ADL [NAME]'s are to be reviewed and updated at Case Management/Care Plan meetings. 1) Resident #2 was admitted to the Facility in April 2023, diagnoses included: cerebral infarction, bilateral carotid arteries occlusion and stenosis, pneumonitis due to inhalation of food, major depressive disorder, weakness, epilepsy, respiratory failure with hypoxia and dementia. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #2 had moderate cognitive impairment and was totally dependent on staff with rolling from side to side in bed. Review of Resident #2's Care Plan related to Mobility, renewed and reviewed with his/her June 2024 MDS, indicated that he/she was dependent on the physical assistance of two staff members with repositioning in bed. Review of Resident #2's Resident Care Card/([NAME], (used as a reference guide by CNA's), (reviewed and updated in conjunction with his/her plan of care), indicated that he/she was dependent on the physical assistance of two staff members with bed mobility, which included turning and repositioning in bed. Review of the Facility's Internal Investigation Report, dated 08/06/24, indicated that on 08/05/24 at 9:10 P.M., a CNA was providing care to Resident #2, turned him/her over onto his/her right side in bed and proceeded to go into the bathroom to get water [leaving him/her unattended] to wash Resident #2. The Report indicated that when the CNA walked into the bathroom, she heard a bang and when she went to check on Resident #2, Resident #2 was lying on the floor beside his/her bed on his/her left side. The Report indicated that Resident #2 was observed to have a bump to the left side of his/her forehead and a bruise to his/her left ankle and left ear. The Report indicated that Resident #2 required the assistance of two staff members with care. The Report indicated that Resident #2 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a left hip fracture. Review of a Nurse Progress Note, dated 08/05/24 (written by Nurse #3) indicated that a CNA (later identified as CNA #2) called her into Resident #2's room, he/she (Resident #2) was observed on the floor and had hit his/her head on the night stand. The Note indicated that Resident #2 had a large bruise to his/her left ankle, left ear and continued to cry out. The Note indicated that 911 (Emergency Medical Services) was called and Resident #2 was transferred to the Hospital. During a telephone interview on 08/28/24 at 12:22 P.M., (which included review of her written witness statement), Nurse #3 said that on 08/05/24, another nurse notified her that Resident #2 was on the floor. Nurse #3 said she immediately ran into Resident #2's room and found him/her lying on the floor with his/her head on the foot of the bedside table, yelling out in pain. Nurse #3 said that the bed was in the high position when she walked into Resident #2's room. Nurse #3 said she asked CNA #2 what happened and said that CNA #2 told her that she was providing care to Resident #2, turned him/her on his/her right side, walked away from him/her to go get clean water in the bathroom, and he/she fell out of bed. Nurse #3 said that Resident #2 was yelling out in pain, had an abrasion to his/her left ear and a bruise to his/her left ankle. Nurse #3 said that Resident #2 required the physical assistance of two staff members with bed mobility and said CNA #2 did not follow Resident #2's plan of care. Review of CNA #2's Written Witness Statement, dated 08/05/24, indicated that she was providing care to Resident #2 in bed, turned him/her on the right side, went into the bathroom to change the water and heard a loud bang when she walked out of the bathroom and saw Resident #2 lying on the floor on his/her left side. During a telephone interview on 8/28/24 at 12:40 P.M., CNA #2 said that she was providing care to Resident #2 in bed and turned him/her on his/her right side in bed. CNA #2 said that she walked into the bathroom to get clean water and just as she was coming out of the bathroom, she heard a loud bang noise and saw Resident #2 lying on the floor on his/her left side. CNA #2 said she had taken care of Resident #2 prior to this incident, and that she knew that Resident #2 required physical assistance of two staff members with bed mobility including turning and repositioning in bed. CNA #2 said that she thought she could provide care to Resident #2, in bed, by herself. CNA #2 said she did not have another staff member with her when she provided care to Resident #2 care and said she did not follow Resident #2's plan of care. During a telephone interview on 8/29/24 at 1:20 P.M., the Unit Manager said that Resident #2 required physical assistance of two staff members with bed mobility, turning and positioning. The Unit Manager said CNA #2 provided care to Resident #2 in bed without the assistance of another staff member and did not follow Resident #2's plan of care. Review of a Hospital Discharge summary, dated [DATE], indicated that Resident #2 fell out of bed at the nursing facility and sustained an acute left intertrochanteric femoral fracture (hip). The Summary indicated that Resident #2 underwent an Open Reduction Internal Fixation (ORIF) surgical repair of his/her left hip. During an interview on 08/27/24 at 2:25 P.M., the interim Director of Nurses (DON) said that Resident #2 was totally dependent on the physical assistance of two staff members with bed mobility, turning and repositioning. The DON said that CNA #2 provided care to Resident #1 in bed without the assistance of another staff member, and Resident #2 fell out of bed and sustained a left hip fracture. The DON said that CNA #2 did not follow Resident #2's plan of care and said that it was her expectation that staff follow the plan of care. 2) Resident #1 was admitted to the Facility in August 2023 diagnoses included: sepsis, osteoarthritis of knee, acute on chronic respiratory failure, dizziness, abnormalities of gait and mobility and muscle weakness. Review of Resident #1's Annual Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was totally dependent on staff with transfers. Review of Resident #1's Care Plans related to Self-Care Deficit and Fall Risk, reviewed and renewed in conjunction with his/her July 2024 MDS, indicated that he/she was dependent on the physical assistance of two staff members with transfers. Review of Resident #1's Resident Care Card/[NAME], (reviewed and updated in conjunction with his/her plan of care), indicated that he/she was dependent on the physical assistance of two staff members with transfers. Review of the Facility's Internal Investigation Report, dated 08/09/24, indicated that on 08/03/24 at approximately 7:00 P.M., a CNA was transferring Resident #1 from wheelchair to bed when Resident #1 pivoted incorrectly while transferring and twisted his/her left ankle. The Report indicated that on 08/04/24, Resident #1 complained of left ankle pain, upon assessment the left ankle was noted to be swollen and bruised, the physician was notified, and an x-ray was obtained. The Report indicated that the results of the x-ray were negative for any fracture. The Report further indicated that on 08/08/24, Resident #1 was transferred to the hospital for complaints of stomach and head pain, and that on 08/09/24, the Administrator received a report from the hospital that indicated that Resident #1 complained of left ankle pain, an x-ray was obtained and revealed a fracture to his/her left ankle. The Report indicated that on 8/16/24, Resident #1 was seen by an orthopedic surgeon, an x-ray was obtained of his/her left ankle and was negative for a fracture. The Report indicated that Resident #1 had a second or third degree left ankle lateral sprain. Review of Nurse Progress Note, dated 8/06/24 as a late entry for 08/04/24, (written by Nurse #2) indicated that Resident #1 complained of pain and screamed out in pain when left ankle was touched by nurse during assessment. The Note indicated that Resident #1's left ankle was noted to be bruised, discolored and swollen. The Note indicated that the physician was notified, ordered an x-ray of Resident #1's left ankle and ice to the left ankle. During a telephone interview on 08/28/24 at 12:54 P.M., Nurse #2 said that on 08/04/24 Resident #1 complained of left ankle pain and upon assessment his/her left ankle was bruised and swollen. Nurse #2 said she notified the physician and obtained an order for an x-ray and ice pack. Nurse #2 said that Resident #1 told her that a male CNA (later identified as CNA #1) transferred him/her to bed by himself the night before (08/03/24) and that he/she (Resident #1) twisted his/her left ankle during the transfer. Nurse #2 said that she asked CNA #1 if he had transferred Resident #1 alone and if during the transfer Resident #1 complained of pain and said CNA #1 told her that Resident #1 said Ow during the transfer. Nurse #2 said that Resident #1 requires physical assistance of two staff members with transfers and said CNA #1 did not follow his/her plan of care. Nurse #2 said that Resident #1 sustained a bad left ankle sprain during the transfer. During a telephone interview on 8/28/24 at 11:49 A.M., (which included review of his written witness statement), CNA #1 said that on 08/03/24 he transferred Resident #1 alone from his/her wheelchair into bed and that Resident #1 hit his/her left ankle on the wheelchair. CNA #1 said Resident #1 complained of left ankle pain during and after the transfer and said he reported it to the nurse. CNA #1 said that he was aware that Resident #1 required the assistance of two staff members with transfers and said he thought he could transfer Resident #1 back into bed alone without the assistance of another staff member. CNA #1 said that he did not follow Resident #1's plan of care. During a telephone interview on 08/27/24 at 12:15 P.M., (which included review of her written witness statement), Nurse #1 said that on 08/03/24, CNA #1 had reported to her that Resident #1 complained of leg pain and wanted Tylenol. but said that CNA #1 did not report to her that Resident #1 had hit his/her left ankle on the wheelchair during the transfer. Nurse #1 said that Resident #1 requires physical assistance of two staff members with all transfers. During a telephone interview on 8/29/24 at 1:20 P.M., the Unit Manager said that Resident #1 required physical assistance of two staff members with transfers. The Unit Manager said CNA #1 transferred Resident #1 without the assistance of another staff member and did not follow Resident #1's plan of care. Review of an Orthopedic Consult Report, dated 08/16/24, indicated that Resident #1 had a second or third degree left ankle lateral sprain. The Report indicated that Resident #1 was to wear a stirrup (used to increase comfort and limit movement after an injury) brace for comfort. During an interview on 08/27/24 at 2:25 P.M., the interim Director of Nurses (DON) said that Resident #1 required the physical assistance of two staff members with transfers. The DON said that CNA #1 transferred Resident #1 without the assistance of another staff member and said Resident #1 sustained a sprained left ankle during the transfer. The DON said that CNA #1 did not follow Resident #1's plan of care. On 08/27/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 08/03/24, Resident #1 was given Tylenol for complaints of leg pain. B. On 08/04/24, Resident #1 was assessed by the nurse, physician was notified of bruising and swelling to left ankle, an x-ray was obtained, ice and Tylenol were implemented. C. On 08/05/24, Resident #2 was assessed, first aid was initiated, 911 was called and he/she was transferred to the ED for evaluation of his/her injuries. D. On 08/09/24, a full house audit was conducted by the Unit Managers of all Resident ADL/[NAME]'s and Care Plans to ensure accuracy, and that the correct level of assistance required by staff for ADL's was indicated. E. On 08/09/24, Resident #2 was re-admitted to the Facility from the hospital and his/her Plan of Care was updated. F. On 08/09/24, the Staff Development Coordinator educated Licensed Nursing Staff and CNA's on the Use of the Resident ADL Guide and Care [NAME]. G. On 8/12/24, staff nurses began observing CNA staff daily on transfers and positioning of residents per interventions identified in their plans of care. H. On 08/13/24, the Staff Development Coordinator educated Licensed Nursing Staff and CNA's on safe lifting and movement of residents. I. On 08/16/24, Resident #1's was seen by an Orthopedic Surgeon and was found to have a second or third degree left ankle sprain and new orders for a stirrup brace was implemented. J. On 08/16/24, the Facility implemented a readmission policy to ensure all paperwork is reviewed and accurate on all new admissions and readmissions. Unit Managers are responsible to complete the checklist daily at morning meeting. K. Unit Managers and/or their Designee will conduct daily audits x 90 days, then weekly thereafter on Resident Care Plans and ADL Guide/[NAME]'s to ensure accuracy. L. The results of the audits will be forwarded to the Corporate Director of Clinical Services weekly. M. The results of the audits will be brought to QAPI meeting quarterly x 3 or until the committee determines compliance. N. The Director of Nursing and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who required the physical assistance of two staff members with transfers and/or bed mobility, the Facility failed to ensure they were provided with the required level of staff assistance in an effort to prevent an accident resulting in an injury. 1) On 08/05/24, Certified Nurse Aide (CNA) #2 provided care to Resident #2 who was in bed, without getting assistance from another staff member, CNA #2 left Resident #2 lying on his/her right side in bed, walked to the bathroom, heard a loud bang and found Resident #2 lying on the floor beside his/her bed on his/her left side. Resident #2 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fractured left hip which required surgical intervention to repair. 2) On 08/03/24, CNA #1 transferred Resident #1 from his/her wheelchair into bed, without getting assistance from another staff member, Resident #1 complained of left ankle pain after the transfer and was diagnosed by an orthopedic physician with a second or third degree (partial to complete tear of the ankle ligament) left ankle lateral sprain which required a brace for comfort. Findings include: Review of the Facility's Policy, titled Falls Policy and Procedure, dated as reviewed December 2023, indicated the following: -fall assessment will be completed upon admission/readmission, after each fall, with any change in medical condition, quarterly and annually; a score of 10 or greater indicates high risk for fall; -licensed nurse must implement interventions to promote resident safety based on the residents risk factors; -if identified as high risk, resident may be placed on the falling star program; -interventions will be added to the resident's care plan and ADL card; -any resident fall is to be reported to the nurse immediately; -resident is to be left as found, not moved until the nurse has completed the assessment; -nursing supervisor on duty shall be notified; -vital signs are to be taken for 48 hours and observations recorded in the nurses' notes; -charge nurse will notify the resident's guardian or responsible party of the fall; -the physician must be notified; -the nurse shall complete the following documentation: fall and initial assessment findings in the nurses notes, the fall in the shift report log book, conduct re-assessment of the resident's fall risk by completing a Fall Assessment, complete the Quality Assessment and Assurance Incident Report, update the care plan and ADL card to include additional falls prevention interventions implemented; - the Quality Assessment and Assurance Incident Report and Post Falls Investigation Report will be forwarded to the Director of Nursing. Review of the Facility's Policy, titled Resident Accident Reporting Procedure, dated as reviewed January 2024, indicated the following: -an accident is defined as any episode which results in visible signs of injury, any resident on the floor, witnessed falls or one in which follow-up treatment or evaluation is necessary; -Licensed Nurses complete the Quality Assessment and Assurance Incident Report; -Report only factual data as seen by yourself or the individual reporting to you; -complete pertinent resident information; -record date and time of accident; -assess resident's condition, identify any potential contributing factors to the accident; -describe in detail and to the extent known, the act and circumstances regarding the accident; -identify any witnesses, and request witness write a statement; -nurse will conduct resident assessment and document symptoms and predisposing factors; -nurse will notify the physician, responsible party and supervisor; -write a nurses note, document change of shift report, monitor and observations recorded in nurses notes for 48 hours; -address in care plan and ADL card; -document all communication with physician; -nurse will modify the care plan as necessary to include measures and interventions initiated to prevent similar accidents. 1) Resident #2 was admitted to the Facility in April 2023, diagnoses included: cerebral infarction, bilateral carotid arteries occlusion and stenosis, pneumonitis due to inhalation of food, major depressive disorder, weakness, epilepsy, respiratory failure with hypoxia and dementia. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #2 had moderate cognitive impairment and was totally dependent on staff with rolling from side to side in bed. Review of Resident #2's Care Plan related to Mobility, renewed and reviewed with his/her June 2024 MDS, indicated that he/she was dependent on the physical assistance of two staff members with repositioning in bed. Review of Resident #2's Resident Care Card/[NAME], (used as a reference guide by CNA's), (reviewed and updated in conjunction with his/her plan of care), indicated that he/she was dependent on the physical assistance of two staff members with bed mobility, which included turning and repositioning in bed. Review of the Facility's Internal Investigation Report, dated 08/06/24, indicated that on 08/05/24 at 9:10 P.M., a CNA was providing care to Resident #2, turned him/her over onto his/her right side in bed and proceeded to go into the bathroom [leaving him/her unattended] to get water to wash Resident #2. The Report indicated that when the CNA walked into the bathroom, she heard a bang and when she went to check on Resident #2, Resident #2 was lying on the floor beside his/her bed on his/her left side. The Report indicated that Resident #2 was observed to have a bump to the left side of his/her forehead and a bruise to his/her left ankle and left ear. The Report indicated that Resident #2 required the assistance of two staff members with care. The Report indicated that Resident #2 was transferred to the Hospital ED for evaluation and was diagnosed with a left hip fracture. Review of a Nurse Progress Note, dated 08/05/24 (written by Nurse #3) indicated that a CNA (later identified as CNA #2) called her into Resident #2's room, and he/she (Resident #2) was observed on the floor and had hit his/her head on the night stand. The Note indicated that Resident #2 had a large bruise to his/her left ankle, left ear and continued to cry out. The Note indicated that 911 (Emergency Medical Services) was called and Resident #2 was transferred to the Hospital ED. During a telephone interview on 08/28/24 at 12:22 P.M., (which included review of her written witness statement), Nurse #3 said that on 08/05/24, another nurse notified her that Resident #2 was on the floor. Nurse #3 said she immediately ran into Resident #2's room and found him/her lying on the floor with his/her head on the foot of the bedside table, yelling out in pain. Nurse #3 said that the bed was in the high position when she walked into Resident #2's room. Nurse #3 said she asked CNA #2 what happened and said that CNA #2 told her, she was providing care to Resident #2, turned him/her on his/her right side, walked away from him/her to go get clean water in the bathroom, heard a loud noise when she came out of the bathroom, that Resident #2 was on the floor and had fallen out of bed. Nurse #3 said that Resident #2 was yelling out in pain, had an abrasion to his/her left ear and a bruise to his/her left ankle. Nurse #3 said that Resident #2 required physical assistance of two staff members with bed mobility and said CNA #2 should have had another staff member present to assist her with Resident #2's care. Nurse #3 said that 911 was called and Resident #2 was transferred to the Hospital for evaluation of his/her injuries and returned to the Facility several days later with a new diagnosis of a fractured left hip. Review of CNA #2's Written Witness Statement, dated 08/05/24, indicated that she was providing care to Resident #2 in bed, turned him/her on the right side, went into the bathroom to change the water and heard a loud bang noise when she was in the bathroom. The Statement indicated that when she (CNA #2) walked out of the bathroom she saw Resident #2 lying on the floor on his/her left side. During a telephone interview on 8/28/24 at 12:40 P.M., CNA #2 said that she was providing care to Resident #2 in bed and turned him/her on his/her right side in bed. CNA #2 said that she walked into the bathroom to get clean water and just as she was coming out of the bathroom, she heard a loud bang noise and saw Resident #2 lying on the floor on his/her left side. CNA #2 said that she knew that Resident #2 required physical assistance of two staff members with bed mobility which included turning and repositioning in bed. CNA #2 said that she had taken care of Resident #2 prior to the incident and said she thought she could provide care to Resident #2 in bed by herself. CNA #2 said she did not have another staff member with her when she provided care to Resident #2. During a telephone interview on 8/29/24 at 1:20 P.M., the Unit Manager said that Resident #2 required physical assistance of two staff members with bed mobility, turning and positioning and said CNA #2 provided care to him/her without the assistance of another staff member and should not have. Review of a Hospital Discharge summary, dated [DATE], indicated that Resident #2 fell out of bed at the nursing facility and sustained an acute left intertrochanteric femoral fracture (hip). The Summary indicated that Resident #2 underwent an Open Reduction Internal Fixation (ORIF) surgical repair of his/her left hip. During an interview on 08/27/24 at 2:25 P.M., the interim Director of Nurses (DON) said that Resident #2 was totally dependent on the physical assistance of two staff members with bed mobility, turning and repositioning. The DON said that CNA #2 provided care to Resident #2 in bed without the assistance of another staff member and Resident #2 fell out of bed and sustained a left hip fracture. 2) Resident #1 was admitted to the Facility in August 2023 diagnoses included: sepsis, osteoarthritis of knee, acute on chronic respiratory failure, dizziness, abnormalities of gait and mobility and muscle weakness. Review of Resident #1's Fall Assessment, dated 07/02/24, indicated that he/she was at high risk for falls. Review of Resident #1's Annual Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was totally dependent on staff with transfers. Review of Resident #1's Care Plans related to Self-Care Deficit and Fall Risk, reviewed and renewed with the completion of his/her July 2024 MS, indicated that he/she was dependent on the physical assistance of two staff members with transfers. Review of Resident #1's Resident Care Card/[NAME], (used as a reference guide by CNA's), indicated that he/she was dependent on the physical assistance of two staff members with transfers. Review of the Facility's Internal Investigation Report, dated 08/09/24, indicated that on 08/03/24 at approximately 7:00 P.M., a CNA was transferring Resident #1 from wheelchair to bed when Resident #1 pivoted incorrectly while transferring and twisted his/her left ankle. The Report indicated that on 08/04/24, Resident #1 complained of left ankle pain, upon assessment the left ankle was noted to be swollen and bruised, the physician was notified, and an x-ray was obtained. The Report indicated that the results of the x-ray were negative for any fracture. The Report indicated that on 08/08/24, Resident #1 was transferred to the hospital for complaints of stomach and head pain and on 08/09/24, the Administrator received a report from the hospital that indicated that Resident #1 complained of left ankle pain, an x-ray was obtained and revealed a fracture to his/her left ankle. The Report indicated that on 8/16/24, Resident #1 was seen by an orthopedic surgeon, an x-ray was obtained of his/her left ankle and was negative for a fracture. The Report indicated that Resident #1 had a second or third degree left ankle lateral sprain. Review of Nurse Progress Note, dated 8/06/24 as a late entry for 08/04/24, (written by Nurse #2) indicated that Resident #1 complained of pain and screamed out in pain when his/her left ankle was touched by nurse during assessment. The Note indicated that Resident #1's left ankle was noted to be bruised, discolored and swollen. The Note indicated that the physician was notified, ordered an x-ray of Resident #1's left ankle and ice to the left ankle. During a telephone interview on 08/28/24 at 12:54 P.M., Nurse #2 said that on 08/04/24 Resident #1 complained of left ankle pain and upon assessment, his/her left ankle was bruised and swollen. Nurse #2 said she notified the physician and obtained an order for an x-ray and ice pack. Nurse #2 said that Resident #1 told her that a male CNA (later identified as CNA #1) transferred him/her to bed by himself the night before (08/03/24) and that he/she (Resident #1) twisted his/her left ankle during the transfer. Nurse #2 said that she asked CNA #1 if he transferred Resident #1 alone and if during the transfer Resident #1 complained of pain and said CNA #1 told her that Resident #1 said Ow during the transfer. Nurse #2 said that Resident #1 requires the physical assistance of two staff members for transfers. During a telephone interview on 8/28/24 at 11:49 A.M., (which included review of his written witness statement), CNA #1 said that on 08/03/24 he transferred Resident #1 alone from his/her wheelchair into bed and that Resident #1 hit his/her left ankle on the wheelchair. CNA #1 said Resident #1 complained of left ankle pain during and after the transfer and said he reported it to the nurse. CNA #1 said that he was aware that Resident #1 required the assistance of two staff members with transfers and said he thought he could transfer Resident #1 back into bed alone without the assistance of another staff member. During a telephone interview on 08/27/24 at 12:15 P.M., (which included review of her written witness statement), Nurse #1 said that on 08/03/24, CNA #1 had reported to her that Resident #1 complained of leg pain and wanted Tylenol, but said that CNA #1 did not report to her that Resident #1 had hit his/her left ankle on the wheelchair during the transfer. Nurse #1 said that Resident #1 requires physical assistance of two staff members with all transfers. During a telephone interview on 8/29/24 at 1:20 P.M., the Unit Manager said that Resident #1 required physical assistance of two staff members with transfers. The Unit Manager said CNA #1 transferred Resident #1 without assistance from another staff member and should not have. Review of an Orthopedic Consult Report, dated 08/16/24, indicated that Resident #1 had a second or third degree left ankle lateral sprain. The Report indicated that Resident #1 was to wear a stirrup (used to increase comfort and limit movement after an injury) brace for comfort. During an interview on 08/27/24 at 2:25 P.M., the interim Director of Nurses (DON) said that Resident #1 required the physical assistance of two staff members with transfers. The DON said that CNA #1 transferred Resident #1 without assistance from another staff member and said Resident #1 sustained a sprained left ankle during the transfer. On 08/27/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 08/03/24, Resident #1 was given Tylenol for complaints of leg pain. B. On 08/04/24, Resident #1 was assessed by the nurse, physician was notified of bruising and swelling to left ankle, an x-ray was obtained, ice and Tylenol were implemented. C. On 08/05/24, Resident #2 was assessed, first aid was initiated, 911 was called and he/she was transferred to the ED for evaluation of his/her injuries. D. On 08/09/24, a full house audit was conducted by the Unit Managers of all Resident ADL/[NAME]'s and Care Plans to ensure accuracy, and that the correct level of assistance required by staff for ADL's was indicated. E. On 08/09/24, Resident #2 was re-admitted to the Facility from the hospital and his/her Plan of Care was updated. F. On 08/09/24, the Staff Development Coordinator educated Licensed Nursing Staff and CNA's on the Use of the Resident ADL Guide and Care [NAME]. G. On 8/12/24, staff nurses began observing CNA staff daily on transfers and positioning of residents per interventions identified in their plans of care. H. On 08/13/24, the Staff Development Coordinator educated Licensed Nursing Staff and CNA's on safe lifting and movement of residents. I. On 08/16/24, Resident #1's was seen by the Orthopedic Surgeon and was found to have a second or third degree left ankle sprain and new orders for a stirrup brace was implemented. J. On 08/16/24, the Facility implemented a readmission policy to ensure all paperwork is reviewed and accurate on all new admissions and readmissions. Unit Managers are responsible to complete the checklist daily at morning meeting. K. Unit Managers and/or their Designee will conduct daily audits x 90 days, then weekly thereafter on Resident Care Plans and ADL Guide/[NAME]'s to ensure accuracy. L. The results of the audits will be forwarded to the Corporate Director of Clinical Services weekly. M. The results of the audits will be brought to QAPI meeting quarterly x 3 or until the committee determines compliance. N. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a splint to secure a fracture he/she sustained to his/her right elbow, the Facility failed to ensure he/she was provided care and treatment that met professional standards for quality of care, when after a follow-up appointment, Resident #1's orthopedic Physician Assistant (PA) made recommendations on the consult form for Nursing to remove the splint and change his/her right elbow dressing daily, until healed. However, the recommendations were not followed up on or implemented by Nursing, the dressing changes were not completed and at his/her next orthopedic follow-up appointment is was discovered that Resident #1 had developed a pressure injury to his/her right elbow. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in February 2024, diagnoses included displaced fracture of lateral end of right clavicle (collarbone), unspecified fall, chronic kidney disease stage 3, diabetes mellitus, Bell's palsy and a displaced fracture of olecranon (elbow) process intraarticular extension of right ulna (long bone in the forearm). Review of Resident #1's Norton Scale Predicting Risk of Pressure Ulcer, dated 03/04/24, indicated he/she was assessed by nursing to be at high risk for the development of pressure injuries. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 03/07/24, indicated that Resident #1 had moderate cognitive impairments and he/she was at increased risk for the development of pressure injuries. Review of Resident #1's Orthopedic Report of Consultation, dated 03/18/24, indicated their recommendations included the following: -Continue with posterior (used to immobilize the elbow) splint -May remove splint for gentle Active Range of Motion (AROM) and Passive Range of Motion (PROM) -Non-weight bearing of right upper extremity -Change right elbow skin tear dressing daily until healed -Follow-up in 3 weeks Review of Resident #1's Weekly Skin Assessments, dated 03/08/24, 03/19/24, 03/26/24, and 04/05/24, indicated that nursing documented that he/she did not have any skin impairments other than multiple bruised areas that were previously identified due to a fractured right clavicle and right olecranon. Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 04/08/24, indicated that on 03/18/24, Resident #1 had an orthopedic appointment with orders to change right elbow skin tear dressing daily. The Report indicated that on 4/08/24 Resident #1 had another orthopedic appointment where he/she was noted to have 1 centimeter (cm) x 1 cm x 0.3 cm stage 4 (full-thickness skin loss with extensive destruction, tissue death or damage to muscle, bone or supporting structures) wound to his/her right elbow. The Report indicated Resident #1 had previously had an order for the splint to be worn on his/her right arm which stated not to remove or get the splint wet. The Report indicated that the nurse who had Resident #1 on her assignment on 3/18/24 did not follow up on the new orders {recommendations} given from the orthopedic appointment. Review of Resident #1's Nurse Progress Note, dated 3/18/24, (written by Nurse #2), indicated that he/she had a splint placed to the right arm, positive Circulation Sensation Motion (CSM) and ortho appointment. Review of Nurse #2's Written Witness Statement, dated 4/10/24, (provided to the Surveyor on the date of the survey), indicated that Resident #1 returned from an orthopedic appointment {on 3/18/24} and the consultation report was placed on the nursing desk. The Statement indicated that Nurse #2 forgot to look at the report for new orders. Review of Nurse #2's second Written Witness Statement, dated 4/11/24, (copy provided via fax to the Surveyor on 5/07/24), indicated that Resident #1 was at an orthopedic appointment {on 3/18/24} and the consultation report was placed on the unit desk. The Statement indicated that she (Nurse #2) was doing her medication pass when Resident #1 arrived back on the unit from the appointment. The Statement indicated that at the end of her (Nurse #2) shift while giving report to the overnight nurse, that her report included that Resident #1 went to an orthopedic appointment, and that she (Nurse #2) had verbalized to the overnight nurse that she had not looked at the paperwork from the orthopedic appointment. The Statement indicated that the overnight nurse agreed to review Resident #1's orthopedic consult paperwork. The Statement indicated that Nurse #2 showed the overnight nurse where the orthopedic consult paperwork was and placed the orthopedic consult paperwork in front of the computer. During a telephone interview on 05/06/24 at 2:35 P.M., Nurse #2 said that Resident #1 returned from an Orthopedic appointment on 03/18/24 with paperwork from his/her Orthopedic Consult during her shift (3:00 P.M. to 10:00 P.M.). Nurse #2 said that she placed the paperwork on the nurse's desk near the Unit Managers computer. Nurse #2 said that she was too busy at that time to review the Orthopedic Consult paperwork. Nurse #2 said that she told the overnight nurse (later identified as Nurse #1 who worked the 10:00 P.M. to 6:00 A.M. shift on 03/18/24 into 03/19/24) that Resident #1 had returned from an Orthopedic appointment, that the paperwork was at the nurse's desk and that she did not have time to review the paperwork for any new recommendations. Nurse #2 said that the next shift nurse (Nurse #1) told her that she would review the Orthopedic Consult paperwork because she had to do the 24-hour checks (reconciliation of past 24-hour physician's orders) anyway. Nurse #2 said that on 4/10/24, facility staff kept pressuring her to write a witness statement that indicated that she forgot to look at Resident #1's 03/18/24 orthopedic consult paperwork for any new orders. Nurse #2 said that the next day, on 04/11/24, she wrote another witness statement that detailed the events that occurred on 03/18/24 during her shift and gave it to a nurse manager at the facility. During an interview on 4/30/24 at 1:30 P.M., Nurse #1 (who was the overnight nurse on 03/18/24 into 03/19/24 and worked 10:00 P.M. to 6:00 A.M. and was assigned to Resident #1) said that she was not aware that Resident #1 had an orthopedic appointment the previous shift. Nurse #1 said that she was not aware that Resident #1 had an Orthopedic Consult on 3/18/24 until his/her 4/08/24 orthopedic appointment in which it was discovered that he/she had orders from the 3/18/24 appointment that were never implemented. Nurse #1 said that she did not get any report from the previous shift nurse (Nurse #2) that Resident #1 had been seen by the Orthopedic on 3/18/24. Nurse #1 said the only physician's orders that Resident #1 had prior to the 4/08/24 Orthopedic Consult was not to remove the right elbow splint, not to get the right elbow splint wet, monitor CSM and skin integrity (health of the skin). Nurse #1 said that after Resident #1 went to his/her 4/08/24 Orthopedic Follow-up Consult, she was told that he/she had recommendation orders from the 3/18/24 Orthopedic Consult that were never implemented and was told that Resident #1 had a Stage 4 pressure injury that was noted during the 4/08/24 Orthopedic visit. Review of Resident #1's Physician Interim Orders, dated 3/18/24 through 4/07/24, indicated there was no documentation to support that an order was obtained from the Physician regarding the recommendations from the Orthopedic PA related to his/her right elbow and transcribed onto his/her Treatment Administration Records (TAR). Review of Resident #1's TAR, dated 3/18/24 through 4/07/24, indicated there was no documentation to support Nursing removed his/her right arm splint and that the right elbow skin tear dressing was changed daily until healed. Further review of Resident #1's Medical Record, dated 3/18/24 through 4/07/24, indicated there were no Nursing Progress Notes with documentation to support Nursing removed his/her right arm splint and that the right elbow skin tear dressing was changed daily until healed. Review of Resident #1's Orthopedic Report of Consultation, dated 4/08/24, indicated he/she was seen for a healing displaced right olecranon fracture with noted pressure sore to his/her right elbow and had recommendations for the following: -Begin AROM and PROM to right elbow -Non-weight bearing to right elbow -Wound Clinic referral for right elbow pressure injury -Wound care for right elbow pressure injury: wet to dry dressing, change twice daily until seen by wound clinic -Follow-up with orthopedic in one week Review of Nurse Progress Note, dated 04/09/24, indicated that Resident #1's right elbow wound presented with purulent (thick discharge that usually implies an infection) substance, Nurse Practitioner (NP) was notified and Kelfex (antibiotic) 500 milligrams (mg) twice a day for 5 days was ordered. Review of Resident #1's Physician's Interim Telephone Order, dated 04/09/24, indicated to start Keflex 500 mg. twice a day, for 5 days. Review of a Physician Progress Note, dated 04/12/24, indicated that Resident #1 was currently on Keflex 500 mg. twice a day, monitor patient clinically and continue with medications as prescribed. Review of Resident #1's Orthopedic Report of Consultation, dated 4/15/24, indicated he/she was seen for a right olecranon fracture with a pressure injury present to his/her right elbow and had recommendations for the following: -AROM and PROM as tolerated -Wound Care for right elbow pressure injury: Continue wet to dry dressing and use Allevyn (foam dressing used to absorb wound exudate (drainage) dressing -Wound clinic referral and wound care per wound clinic physician -Follow-up with orthopedic in two weeks During a telephone interview on 5/06/24 at 8:40 A.M., the Orthopedic Physician Assistant (PA) said that Resident #1 was seen on 3/18/24 for a right elbow fracture. The Orthopedic PA said that Resident #1's right elbow was in a posterior splint, that a skin tear was noted, and he recommended that the splint be removed daily for AROM and PROM and for a dressing to be applied to the skin tear daily and a follow-up appointment was scheduled in 3 weeks. The Orthopedic PA said that there was no pressure injury noted to his/her right elbow at that time. The Orthopedic PA said that on 4/08/24, Resident #1 returned for his/her follow-up appointment, and it was discovered that he/she had a Stage 4 pressure injury to his/her right elbow. The Orthopedic PA said that he recommended that the splint be removed for AROM and PROM and he made recommendations for the treatment of the right elbow pressure injury which included a wound clinic consultation and a follow-up in 1 week. The Orthopedic PA said that on 4/15/24, Resident #1 returned for his/her follow-up appointment, and he made treatment changes to the right elbow pressure injury and recommended a wound clinic consultation and a follow-up appointment in 2 weeks. Review of Resident #1's Wound Clinic Report, dated 4/18/24, indicated that he/she was seen for a stage 4 pressure injury to his/her right elbow which measured 0.3 cm x 0.4 cm x 0.5 cm with undermining (erosion under the wound edges, resulting in a large wound with small opening), serosanguinous (containing both blood and serous fluid), exposed subcutaneous tissue and bone. The Report indicated that the pressure injury had a medium amount of necrotic (dead cells) tissue with a small amount of granulation (new connective tissue) and epithelialization (restoration of the damaged epithelium). The Report included recommendations for treatments and follow-up. During a telephone interview on 05/02/24 at 1:21 P.M., the Unit Manager said that Resident #1 had an orthopedic consultation on 03/18/24 that included recommendations that were not implemented. The Unit Manager said it was the responsibility of the nurse who was assigned to Resident #1 to review the consultation for any recommendations and to ensure that the recommendations were implemented. The Unit Manager said that she was not aware of any new recommendations that were made on the 03/18/24 orthopedic visit and said that she did not review Resident #1's 03/18/24 Orthopedic Consultation Report. The Unit Manager said that Resident #1 went for a follow-up orthopedic consultation on 04/08/24 and that was when she was made aware that he/she had developed a stage 4 pressure injury to his/her right elbow, and she was made aware that on 03/18/24 there were orthopedic consultation recommendations that were not implemented. The Unit Manager said that the facility did not have any specific policy and procedure on consultations. During an in-person interview on 04/30/24 at 2:35 P.M. and a follow-up telephone interview on 05/07/24 at 12:13 P.M., the Administrator said that Resident #1 was seen by the Orthopedic on 03/18/24 for his/her right elbow fracture, that recommendations were made and somehow the recommendations were missed and not implemented. The Administrator said that Resident #1 saw the Orthopedic again on 04/08/24 and it was discovered that he/she had developed a Stage 4 pressure injury to his/her right elbow. The Administrator said that it was his expectation that all consultations are reviewed by the nurse and the Unit Manager to ensure that any recommendation is implemented. The Administrator said it was the responsibility of the Unit Manager to follow up on all consultations to ensure that recommendations were implemented. On 04/30/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 04/08/24, Resident #1 was seen by the Orthopedic with new orders for daily dressing changes to right elbow stage 4 area, posterior splint with orders to remove splint for AROM and PROM, a follow-up Orthopedic Consultation and wound clinic consultation. B. On 4/08/24, the Facility developed a Policy and Procedure on the Clinical Protocol for diagnostic test results and consultations. C. On 04/08/24 and 04/12/24, the Staff Development Coordinator educated Licensed Nursing Staff on the new Policy and Procedure - Clinical Protocol for diagnostic test results, Consultations and notification of the physician of any new orders, reviewing consultation forms, transcribing any new orders and updating the facility physician with any new order recommendations. D. On 04/12/24, a whole house audit was conducted by the Unit Managers of all resident consultation appointments since January 2024 to verify that all recommendations were followed through on by Nursing. E. On 04/12/24, Resident #1's Plans of Care were reviewed and updated with interventions related to his/her right elbow wound interventions. F. On 04/15/24, Resident #1 was seen by Orthopedic, consultation recommendations were reviewed, physician was notified, and new orders were implemented. G. On 04/18/24, Resident #1 was seen at the Wound Clinic, recommendations were reviewed, physician was notified, and new orders were implemented. H. Unit Managers and/or their Designee will conduct daily audits x 90 days, then weekly thereafter on Consultations, New Orders, Physician notification and Implementation of any new orders. I. The results of the audits will be brought to QAPI meeting quarterly x 3 or until the committee determines compliance. J. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on observations, record reviews, and interviews, the facility failed to ensure the nutritional status was maintained for one Resident (#49), out of a total sample of 19 residents. Specifically, the facility failed to address and implement the Dietitian's recommendations promptly, to provide supplements, to provide supervision and/or assistance during meals and assess his/her cognition secondary to mental status changes, in a timely manner, resulting in continued weight loss. Findings include: Resident #49 was admitted to the facility in October of 2020 with diagnoses that included traumatic brain injury. Review of the Minimum Data Set (MDS) assessment, dated 6/14/21, indicated Resident #49 scored 13 out of 15 on a Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact. The MDS indicated the Resident required extensive assistance in transfers, dressing, bathing and eating, weight status at 146 pounds and height of 63 inches. Review of Resident #49's weight record indicated: - 5/07/21 - 144 pounds - 6/10/21 - 145 pounds - 7/09/21 - 133 pounds Review of the 7/10/21 Comprehensive Nutrition Assessment indicated Resident #49 weighed 133 pounds, was dependent and required assistance when he/she ate and drank. The assessment indicated both the Resident's physical and mental conditions affected his/her nutritional status, having had a surgery in June 2021. The assessment identified the Resident with a significant weight loss in 1 month, 12 pounds, 8 % in one month and a decline of 50% in his/her meal intake. At the time of the assessment, the Dietitian indicated Resident #49 had been delusional and is hallucinating - she questioned how this may be influencing the Resident's intake. The Dietitian considered the weight loss clinically significant and altered the plan of care. She recommended: - 120 milliliter (ml) house supplements, twice a day, - Increase supervision - assistance during meals - Assess the influence of his/her mood status is having on his/her intake - Important MD and Responsible representative be made aware. On 7/12/21, the weight record indicated a weight of 139 pounds. Review of the Dietitian's progress note, dated 7/12/21, indicated she was aware of the weight obtained on 7/12/21 of 139 pounds, a six pound gain. The Dietitian documented that the method of weighing the Resident had been inaccurate. The Dietitian documented the Resident's weight loss from June to July of 12 pounds in one month (8%) as significant and the Resident's intake had been declining. The Resident was eating only 50% of his/her meals. The Dietitian recommended nutritional supplements be started twice a day for added calories. Record review indicated the supplements were not initiated after the recommendations made on 7/10/21 and 7/12/21 and no additional weights were obtained to ascertain the accuracy of the weight obtained on 7/12/21. On 7/13/21, the Dietitian completed an Interdisciplinary Communication Form on 7/13/21 with the following recommendations: - 120 ml house supplements, twice a day, - Increase supervision - assistance during meals - Assess the influence of his/her mood status is having on his/her intake - Important MD and Responsible representative be made aware. Review of the clinical record failed to indicate the facility acted upon the recommendations, as there was no indication the Resident's Physician and responsible representative were notified of the significant weight loss and concerns associated with the weight loss, and the house supplements were not ordered. On 7/22/21, the weight record indicated the Resident was 133 pounds, a significant weight loss of 12 pounds from his/her June weight. On 7/27/21, the Dietitian completed a second Interdisciplinary Communication Form. The Dietitian identified Resident #49's significant weight loss and his/her decline in intake of 50% of his/her meals. The Dietitian documented that this was a second request and to start the supplements, to provide increased supervision at meals to prevent further weight loss and to notify the Physician and responsible representative. Review of the Nurse Practitioner (NP)'s progress note, dated 7/27/21, indicated the weight loss was addressed. The NP ordered the house supplements and requested staff to provide increased supervision at meals. Record review indicated the house supplements were not started until 8/2/21. The original recommendation was made on 7/13/21 and the second request was made on 7/27/21. There was no explanation for the delay in implementing the interventions. On 8/6/21, the weight record indicated Resident #49 weighed 131 pounds, a loss of two pounds, and indicated the Resident continued to lose weight. On 8/9/21, the Dietitian completed a third Interdisciplinary Communication Form. She identified Resident #49 having further weight loss and his/her intake remains less than 50%. She recommended super cereal for breakfast and to increase the house supplements from twice a day to three times a day. On 8/10/21 at 8:15 A.M., 8/10/21 at 12:15 P.M., on 8/11/21 at 12:00 P.M., on 8/16/21 at 8:10 A.M., on 8/17/21 at 11:50 P.M. and 8/18/21 at 12:30 P.M., the surveyor observed Resident #49 receive his/her meal in his/her room. On all days the Resident was in bed and staff brought the tray to the room, set the tray in front of the Resident and left the room. The surveyor did not observe the staff providing supervision and assistance as ordered by the Resident's Physician. On 8/10/21 at 12:15 P.M., the breakfast tray was left on the Resident's night table and in appearance the breakfast tray looked as if it had not been consumed much of it. The Resident was eating his/her lunch and said he/she did not like the meal. The Resident said he/she needed the staff, but could not reach the call light. The staff was notified of the Resident's request. Staff was not observed assisting with the Residents' meal. During an interview on 8/17/21 at 9:30 A.M., Certified Nursing Assistant (CNA) #3 and CNA #4 said the CNAs were updated on resident care such as feeding etc. with a care card. The care card provided them with a quick reference about specific resident care areas, such as feeding. The CNAs were unable to locate a care card for Resident #49 on the unit to use at the time of survey. Both CNAs said Resident #49 ate in his/her room and was a set up. Neither staff was aware of the need for supervision or assistance to prevent further weight loss. During an interview on 8/17/21 at 11:30 A.M., Unit Manager (UM) #2 said the Dietitian's recommendations were delayed and not implemented because they had been left in a folder. She said she found the recommendations in the folder and did not know why no one had addressed it sooner. UM #2 was unaware that the Resident was supposed to be supervised during meals to increase his/her intake or to be assessed for mental status changes.