**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1) Prevent bruising and sling indentations on both thighs during a mechanical transfer for 1 resident (Resident #102), and 2) Ensure that 1 resident (Resident 106) was free of injury of an unknown origin (fracture of the leg) of 2 residents observed for transfer and injury of unknown origin, resulting in 2 sling indentations on the thighs and a bruise on the outer right knee with the possibility of developing skin breakdown and a fracture of the leg, pain and hospitalization.Findings Include:Resident #102: Review of the face Sheet, care plans dated 6/25, nursing notes dated 7/23/25 and physician orders dated 7/23/25, revealed Resident #102 was [AGE] years old, alert but not able to make her own healthcare decisions, immobile, and totally dependent on staff for all Activities of Daily Living/ADL’s. The resident was receiving Hospice services at the facility and malnourished weighting 74.6 pounds. The resident’s diagnosis included, protein-calorie malnutrition, fracture of the right tibia, impulsiveness, Alzheimer’s disease, Dementia, pelvic and perineal pain, degeneration of brain, anxiety, mood disturbance, major depression, adjustment disorder and Dysphagia (difficulty swallowing). Review of the facility ADL care plan dated 1/25, stated “use mechanical lift for all transfers, small sling size.” Observation was made on 7/23/25 at 9:50 a.m., of Hospice staff members (Nurse, LPN “F” and Aide “E”) transferring Resident #102 from bed to the shower chair. When this surveyor entered the resident’s room, the resident was not covered and then Hospice Aide “E” quickly covered her with 2 small white towels (a bath blanket was folded sitting in the chair) to the left of the resident’s bed. As Nurse “E” and Aide “F” were lifting the sling with the Hoyer, Resident #102 was talking Spanish and said the word “shoulder” and then the rest was in Spanish (the resident had documentation of pain in her right shoulder due to osteoarthritis), the resident was crying/winning with facial grimacing of pain noted. This surveyor noticed a red indication mark on the resident’s left thigh, the same indication shape as the sling material. A second observation of Resident #102 was done on 7/23/25 at 10:05 a.m., with Nurse Managers, RN’s “C” and “D”; she was in the shower with Hospice Aide “E” giving her a shower. An irregular round shaped bruised area on her right outer knee was observed at this time. The bruise was red/blue in color, and it matched up to the pattern of the large sling she was sitting on; unable to do an observation of all skin due to being transferred into the shower chair. Review of the facility New Skin Condition form dated 7/23/25, at 10:15 a.m. (after this surveyor observed a bruise and lift indication on leg), stated “This writer was notified that this patient had been observed transferring from wheelchair to shower chair by hospice nurse and hospice in a Hoyer sling around the back of the thighs indenting into skin. No bath blanket present. Bruise noted above lateral right knee 4.5 cm x 3 cm blue in color (newly acquired). Attempted to assess while patient was still in shower chair. Unable to fully assess areas where sling was with patient in chair. Intervention: Smaller Hoyer sling brought into room for transfers. Hospice Aide and Hospice Nurse transferred patient to bed. Skin assessment completed at this time. Bruise noted above lateral right knee 4.5 cm x 3 cm blue in color. Left 4th toe bruise dark purple 1 cm x 0.5 cm. Sling indentation noted to the back left thigh and right thigh. Left hip red indentation measuring 4.5 cm x 0.2 cm. Right hip red indentation 12 cm x 0.2 cm.” Review of facility nursing progress note dated 7/23/25 at 11:21 a.m., stated “This writer was notified that this patient had been observed transferring from wheelchair to shower chair by hospice nurse and hospice in a Hoyer sling around the back of the thighs indenting into skin. No bath blanket present. Bruise noted above lateral right knee 4.5 cm x 3 cm blue in color (newly acquired). (Family Member #1), Administrator, DON (Director of Nursing) notified. Intervention small Hoyer sling in room.” During an interview done on 7/23/25 at approximately 10:10 a.m., Nurse Manager “D” had gone and gotten a size small Hoyer sling; when asked where she got it, she stated “in the laundry room.” The facility had available a size small sling and it was documented to use a small sling on her ADL care plan dated 1/25. Review of a physician's order, dated 7/23/25, stated “Monitor bruising q (every) shift until healed to left 4th toe and above lateral right knee until healed.” Review of the facility Altercation in skin integrity care plan updated on 7/23/25, stated “Bruise to lateral rt (right) knee, 6/13/25 (previously, the resident had a bruise the same location as on 7/23/25), ensure size small sling is used for all transfers.” Review of facility staff education dated 7/23/25, revealed the Director of Nursing educated nurse’s and Nursing Assistant’s/CNA's regarding proper Hoyer sling size usage. Review of the facility Transfer Using a Lift policy dated 7/17/25, stated “Ensure the proper size sling is used based on the resident’s size and weight.” Resident #106: Record review of Resident #106’s ‘Injury of unknown origin’ incident report dated 7/18/2025 at 4:28PM revealed Resident #106 had right ankle bruising, swelling and was hot to the touch. In facility Xray was ordered with acute fracture of the fibula and tibia bones with displacement and soft tissue swelling. Pain assessment noted occasional moan or groan, facial grimacing, rigid, fist clenched, knees pulled up, pulling or pushing away and striking out. Both lower extremities with severe contractures and overlap each other. Record review of Resident #106’s electronic medical record revealed and elderly female with medical diagnoses of: muscle weakness, dysphagia, protein calorie malnutrition, diabetes, mood disorder, insomnia, major depressive disorder, Alzheimer’s, gastro-esophageal reflux disorder, hypertension, peripheral vascular disease, irritable bowel syndrome, osteoarthritis, heart disease. A Brief interview of mental status (BIMs) score of 4 out of 15, severe cognitive impairment was noted. Record review of Resident #106's medical record revealed the resident was non-ambulatory/non-weight bearing and had bilateral lower extremities contractures. Observation and interview on 7/22/2025 at 11:58AM with Resident #106 regarding her tibia and fibula (leg bones) fractures revealed: “I don’t know what happened, it just started hurting. It was hurting so badly, and then they sent me to the hospital. It hurt so badly, I couldn’t stand it anymore”. Observation of Resident #106’s right leg/foot gray plastic orthopedic boot to immobilize the right foot/leg. Resident #106 was lying in bed with family members at bedside visiting. In an interview on 7/22/2025 at12:04PM with Resident #106’s family member “G” revealed that the family was called on Friday to see if Resident #106 could go to emergency room (ER). The family member stated that they had called ER around 10:30PM that night and they told them it was a fractured leg, and they asked the ER how that could happen. The family member told them Resident #106 can’t turn herself or roll over and could not stretch out her legs (contractures bilateral lower extremities), was non-weight bearing and basically bedridden. The family member stated that the ER stated that they did not know how this happened because the resident was non-mobile. They had stated that they had asked the facility/nursing home, and no one knew anything. The family member stated that if it was brittle bones the ER and x-rays would have stated so. The family member “G” stated that “So, we have no clue what happened. We were here last Tuesday (7/15/2025) visiting, and she complained of her leg hurt. Usually, her right leg is folded under her left leg at the knee and contracted in that position. She is totally bedridden with a Hoyer lift for transfers but chooses not to get out of bed”. In an interview on 7/22/2025 at 2:00PM Certified Nurse Assistant (CNA) “H” revealed that she was changing Resident #106’s brief on that 7/18/2025 in the morning and noted the resident’s right ankle/leg was swollen and the way she was laying you could not see any coloration. I did notice it had swelling and then when she turned Resident #106 that was when she noticed the color of bruising, color of yellow, purple and green, that was not a fresh bruise. CNA “H” called nurse, licensed Practical Nurse (LPN) “I”. CNA “H” stated “LPN “I” took forever to go to the room, so I snap a photo of just the ankle to take to the LPN “I”, at the end of my shift, we work 6AM to 6PM, only LPN “I” was leaving early that day around 2:00PM, to go to a casino or something. CNA “H” stated that she brought the photo to the LPN “I” to visualize that she needed to go look at the bruising. LPN “I” then went to the Resident #106’s room to look at the leg, CNA “H” went with the LPN “I” and nurse said it was from the mattress, a red pressure area. So LPN “I” put soft Provalon boot on Resident #106, to relieve the pressure, and did not report the change of condition, but reported to the next nurse (Registered Nurse “D”) it was just a red mark. CNA “H” went up to Registered Nurse “D” to make sure that LPN “I” reported it to her. LPN “I” had only stated a red spot and did not report any bruising. Once again CNA “H” showed the photo to RN “D” and then to the Director of Nursing (DON) and Nursing Home Administrator (NHA) and that’s when things got moving. The DON/NHA all went to the resident room and looked at the leg, got x-rays, and sent her out to the hospital. CNA “H” stated that Resident #106 does not stand, does not walk, cannot roll over by herself, cannot move her legs or spread them. Record review of the electronic medical record revealed that there was no documented physical assessment on 7/18/2025 for the bruising or red marks by LPN “I”. Under the skin/wound tab there were no photos of the bruising or of skin monitoring. In an interview on 7/23/2025 at 9:23 AM with the Director of Nursing (DON) there is no nursing assessments policy, in the electronic medical record program there is an admission assessment in the program. We use the nurse’s judgement to assess the resident condition and document the changes. The skilled rehab residents are assessed daily, and the Long-Term Care (LTC) are done monthly. Any change in condition is the responsibility of the nurse’s education and judgement. We train the staff and nurses to identify the changes in residents. In an interview on 7/23/2025 at 9:36AM with Registered Nurse (RN) D regarding Resident #106's fracture ankle incident: The Certified Nurse Assistant (CNA) H came up to me and stated that Resident #106's leg was red, we had 3 nurses for all halls and so I did not have her until the previous nurse Licensed Practical Nurse (LPN) I, left the shift early around 3PM. Licensed Practical Nurse (LPN) I, in report very vagally stated that Resident #106’s leg was red from laying on the leg. It was a weird report from her, and not 10 minutes later the Certified Nurse Assistant (CNA) H came and asked me what did (LPN) I tell you about Resident #106's foot? I stated that (LPN) I told me it was red in a spot from the resident lying on the foot. I went to the room with Certified Nurse Assistant (CNA) H, and there was a soft Prevalon boot on the foot/ankle which had no order for the boot. Licensed Practical Nurse (LPN) I had not gotten an order for the boot. I peeled back the Velcro straps on the right foot/ankle and saw it was swollen, warm to the touch and bruising of yellow/purple/green in color. As soon as I touched the boot Resident #106 moaned n pain, so I did not take the boot off. I went to get the Director of Nursing and then the wound nurse and the unit manager were in the office when I went to tell them what was going on. So then I stated it looks broke, and I want an Xray, they assisted in getting the order from doctor, and then I was still present when the Xray tech/guy came and I sent in Certified Nurse Assistant (CNA) H to assist him, and the Xray guy stated unofficial report of fracture and not to move her. There was another resident here that had a fracture, and she was immobile also. They got the Xray results and sent Resident #106 out after I left at 6PM, Resident #106 has contracture of the legs and had no other areas of concern, for me her legs are a fragile spot; to turn her we have to use the lift sheet and assist both legs. Resident #106 is basically bed bound so it has to have been with her turning. Record review of Resident #106’s Emergency/hospital record dated 7/18/2025 revealed the resident came from nursing home facility due to concerns for right lower extremity ankle swelling. The nursing home facility staff was unable to tell emergency transport when the ankle first started swelling, however they just noticed it today. Unsure of the length of time since the injury. Musculoskeletal assessment: Contractures bilateral lower extremities, pulses intact bilaterally, right ankle swollen, obvious deformity, bruising. Lateral X-ray results: There is acute distal right tibial fracture as well as distal fibular fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Numbers 1256062 and 2564418.Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures for fall prevention for two residents (Resident #101 and Resident #105) of three residents reviewed, resulting in a lack of planned interventions, a lack of implementation of meaningful interventions to prevent falls, resulting Resident #101 and Resident #105 experiencing falls with injuries necessitating emergency medical treatment, unnecessary pain, and a decline in overall health status. Findings include: Resident #101: Review of Intake documentation revealed concerns that on 6/24/25 a staff member was giving Resident #101 a bed bath and the Resident rolled out of the bed because there was only one staff member assisting the Resident when they required the assistance of two staff per their care plan. As a result of the fall, Resident #101 suffered a broken hip which required emergency surgery. On 7/22/25 at 12:50 PM, Resident #101 was not in their room. The Resident’s bed was positioned against the wall and a fall mat was in place on the floor beside the bed. At 1:00 PM on 7/22/25, Resident #101 was observed sitting in a Broda chair (specialized wheeled, reclining chair with solid footrests used for individuals with limited mobility). Certified Nursing Assistant (CNA) “J” was feeding the Resident lunch. When queried regarding care in the facility, Resident #101 stated, “I fell, and they had to put screws in me. I broke my hip.” A follow-up interview was completed with Resident #101 on 7/22/25 at 1:23 PM in their room. When queried what happened when they fell, Resident #101 stated, “I rolled out the bed real hard. Landed on the floor real hard.” When queried if the fall mat was in place beside the bed when they fell, Resident #101 replied, “Didn’t have that mat there then. They just put that mat down.” Resident #101 was queried regarding the height of the bed when they fell and stated, “About a foot higher than it is now.” The bed was noted to be at waist height. When asked why the bed was so high, Resident #101 replied, “I don’t know.” Resident #101 was then asked if there were staff in the room at the time of the fall and responded that a CNA was in the room. When asked what they were doing, Resident #101 stated, “Supposedly cleaning me up but only had one person (CNA). They were supposed to have two (CNAs).” Resident #101 was asked why only one CNA was cleaning them up if there are supposed to be two staff to assist them and replied, “I don’t know. That what they do around here.” When queried what happened after they fell, Resident #101 stated, “(The CNA) went screaming and the nurses came in and they had to get a lift to get me off the floor.” Resident #101 was asked if they went right to the hospital and stated, “I went to (one hospital) and they didn’t find nothing wrong so I went to (different hospital) and they said they needed to do emergency surgery and that’s what they did.” When queried what was broken, Resident #101 revealed they broke their hip and had to get a plate and screws. Resident #101 revealed (Family Member “L”) would be able to provide additional information regarding the care they received and requested they be contacted. Record review revealed Resident #101 was originally to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included displaced intertrochanteric right hip fracture, falls, chronic kidney failure with dialysis dependence, heart failure, left below the knee amputation (LBKA), and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, dependent upon staff for bed mobility, and required total assistance from staff for transfers. Review of Resident #101’s Electronic Medical Record (EMR) revealed a care plan entitled, “Skilled Therapy/ADL: Self-care deficit, require assist with ADLS r/t (related to) limited mobility, debility, and impaired balance” (Initiated: 1/17/25). The care plan included the intervention: - “Bathing: I need extensive assist with 2 people to help me” (Initiated: 1/17/25) - “Bed mobility: I need extensive assist of 2 to help me” (Initiated: 1/17/25) - “Toileting: I need extensive assist of 2 to help me” (Initiated: 1/17/25) - “Transfers: I need extensive assist of 2 to help me” (Initiated: 1/17/25) Review of progress note documentation in Resident #101’s EMR revealed the following: - 6/24/25 at 10:00 AM: “Follow-up/Monitoring… Has the resident reported changes in their experience of pain? Yes, pain in right shoulder and right hip. Has the resident reported changed in their ability to perform ADL tasks or mobility? Yes, cannot flex right shoulder… Have any new orders been received… Yes, X-rays for nasal, right shoulder, and right hip.” - 6/24/25 at 10:14 AM: “Health Status/Progress Note… Resident observed lying on back, next to bed. Head against nightstand. Resident stated doesn't know what happened. He also stated that fell on the right side of body before lying on back; pain in right shoulder and right hip… answered yes when asked if hit head… Swelling noted to left nare. Hand grasp equal and strong but cannot flex right shoulder. Movement in lower extremities. Complaints of pain noted… Orders for x-ray of the nasal bones, right shoulder, and right hip have been placed. To prevent future falls during dressing, care plan will be updated to extensive two assist for dressing.” - 6/25/25 at 3:44 AM: “Health Status/Progress Note… Guest just returned from (Hospital) for right sided pain. X-Ray of 2 View right ankle and right shoulder complete were all negative of fracture and breakage…” - 6/25/25 at 10:17 AM: “Plan of Care… IDT met to review fall. Resident was receiving care from the aide and was rolled on to side when the aide turned to get more needed items (Resident #701) lost grip on the side of the bed and rolled out of bed. Resident was assessed and reported right hip and shoulder pain… Intervention is to have care plan updated to have 2 person assistance with self care to reduce the risk of falls.” - 6/25/25 at 9:00 PM: “Health Status/Progress Note… Guest transferred to hospital on stretcher… Guest demanded be sent to hospital… stated The pain medication is the same medication I was taking already. It's not helping. I want to go to (different Hospital) .” - 6/25/25 at 2:35 PM: “Health Status/Progress Note… Dr into see guest. New order given for Baclofen (muscle relaxer) 5 mg (milligrams) q (every) 8 hours for muscle spasms…” - 7/8/25 at 4:37 PM: “admission Note… Client arrived to facility via (ambulance), on stretcher… Wound vac to right hip, catheter in place and draining yellow fluid… Client c/o pain in hip…” - 7/10/25: Physician “History and Physical… Chief Complaint / Nature of Presenting Problem: Fall… presents to the hospital after a fall. The patient was found to have been treated for right lesser trochanteric fracture, fall, urinary tract infection with MDRO (Multi Drug Resistant Organism) … Upon my exam… admitting to pain of the right hip… patient has profound weakness… moves left upper extremity with severe weakness of the right upper extremity… does not move the right lower extremity… has a left above-knee amputation… toes were amputated from right foot… Plan: right lesser trochanteric fracture: Pain management… Follow-up with orthopedic surgery as indicated.” Resident #101’s Census List documentation in the EMR revealed the Resident was transferred to the hospital on 6/25/25 and returned to the facility on 7/8/25. Upon request for Resident #101’s Incident and Accident (I and A) reports and facility investigations, one I and A with investigation documentation was provided. Review of the I and A revealed: - “6/24/25 9:45 AM… Incident Location: Resident’s room… Nursing Description: Resident observed lying on back, next to bed. Head against nightstand. Resident Description: Resident stated doesn’t know what happened… stated fell on the right side of body before laying on back, pain in right shoulder and right hip… answered yes when asked if hit head… Injuries Observed at Time of Incident… Injury Type: Unable to Determine… Location: Face…” - Undated, Signed Statement by CNA “K”: “I was doing a routine bed bath on (Resident #101) and I had finished washing front and turned (Resident) on left side towards me to make sure they were securely on their side. Once I knew (Resident #101) was secure and holding the side of the bed, I walked around to the opposite side of the bed and went to wash their back. I noticed (Resident #101) reach down and before I could say anything or at least try and catch them, they rolled off the bed and landed on right side going down. Nurses were notified.” - Printed EMR progress note and assessment documentation An interview was conducted with Family Member “L” on 7/23/25 at 8:28 AM. When queried regarding Resident #101’s fall at the facility, Family Member “L” stated, “(Facility) called me on 6/24 or 6/25 and told me that (Resident #101) was getting washed up and the CNA told them to turn over to get the other side but (Resident #101) can’t turn because they are paralyzed.” Family Member “L” then stated, “How do you wash somebody up yourself and turn them when you don’t have no body on the other side?” When queried regarding Resident #101’s mobility including ability to use their arms to help reposition themselves, Family Member “L” revealed the Resident can use one arm “most of the time” but not consistently. Family Member “L” verbalized Resident #101 did not have anything to hold on to if they were on their side and indicated the Resident may be able hold a bed rail if there was one. When queried if the facility had ever assessed or discussed enabler bars or bed rails for Resident #101 to assist with positioning, Family Member “L” responded they were told they could not have any rails on beds because of State regulations. Family Member “L” was asked if the facility provided any other information related to how Resident #101 fell and indicated they did not. Family Member “L” stated, “I know (Resident #101) didn’t roll over themself.” Family Member “L” then stated, “(Resident #101) fractured their hip and leg.” When queried when the facility sent the Resident to the hospital, Family Member “L” revealed Resident #101 went to the ER at two different hospitals. With further inquiry, Family Member “L” revealed the first hospital ER the Resident went to “couldn’t find anything” wrong and sent the Resident back to the facility. Family Member “L” was queried what happened after Resident #101 returned to the facility and replied, “That same night (Resident #101) kept calling me and saying they were having pain. I called (the facility) and said I wanted them to send (Resident #101) out” to a different hospital.” Family Member “L” continued, “The nurse said they had to talk to the Director of Nursing (DON) before they could send (Resident #101) out” to a different hospital. When asked if Resident #101 was transferred to the other hospital ER then, Family Member “L” revealed the Resident was not sent to ER until the night of 6/25/25. Family Member “L” revealed they were informed Resident #101 needed to have emergency surgery in the morning when they got to the hospital. Family Member “L” then stated, “(Resident #101) had to rod in their leg and screws in their hip.” When asked, Family Member “L” revealed Resident #101 was in the hospital for over a week following the fall and surgery to repair the fracture. On 7/23/25 at 10:05 AM, an interview was conducted with Licensed Practical Nurse (LPN) “M”. When queried regarding Resident #101’s fall on 6/24/25, LPN “M” verbalized they were not working when the Resident fell. LPN “M” was then queried regarding the Resident’s upper extremity mobility and revealed the Resident has some “gross motor skills but not fine motor skills.” When queried if the Resident is able to grasp items and hold them, LPN “M” replied, “Some days (Resident #101) can feed themselves and some days can’t.” When queried if Resident #101 would be able to hold and/or grasp an enabler bar in bed to assist with positioning, LPN “M” indicated they may be able to. LPN “M” was then asked if Resident #101 had been assessed for enabler bars and replied, “We don’t have that stuff here.” An interview was completed Registered Nurse (RN) “O” on 7/23/25 at 10:13 AM. When queried if they were working on 6/24/25 when Resident #101 fell, RN “O” confirmed they were. When asked what happened, RN “O” stated, “I was on the hall. (Resident #101) fell when I was passing meds.” RN “O” continued, “During med pass one of the CNAs came out and let me know” Resident #101 fell. RN “O” was asked what happened and stated, “The CNA said they were doing hygiene care and (Resident #101) lost their grip on the side of the bed.” When queried what they observed when they entered the Resident’s room after being notified of the fall, RN “O” replied, “(Resident #101) was on the left side of the bed with their head by nightstand. I documented everything” in the EMR. When asked how high the bed was and how far the Resident fell, RN “O” replied, “Like waist high.” When queried regarding their assessment following the fall, RN “O” revealed the Resident complained of pain in their leg and hip.” With further inquiry, RN “O” revealed they put “muscle rub” on Resident #101’s hip and put in orders for a nasal and hip x-ray. When asked why a nasal x-ray was ordered, RN “O” replied, “Looked like it was swelled.” When asked if they noted any abnormalities in Resident #101’s leg, RN “O” replied, “(Resident #101) landed on right on their hip” and indicated they did not observe any signs/symptoms of obvious fracture. When queried, RN “O” revealed the CNA was providing care to Resident #101 by themselves. RN “O” was asked if Resident #101 was care planned to be one assist for bed mobility and ADL care and revealed they were supposed to be two -assist. RN “O” revealed they reviewed the care plan following the fall and made Resident #101 an “extensive two assist for everything.” On 7/23/25 at 10:17 AM, an interview was conducted with CNA “K”. When queried regarding Resident #101’s fall from their bed on 6/24/25, CNA “K” stated, “I was just doing a routine bed bath.” CNA “K” verbalized they turned the Resident and told them to hold onto the metal bed frame. CNA “K” revealed the Resident fell when they went to walk to the other side of the bed to wash the Resident. CNA “K” stated, “(Resident #101) was reaching for something and let go (of the metal bed frame).” When asked if there was something on the floor that the Resident was reaching for, CNA “K” replied, “No.” When asked how they knew the Resident was reaching down when they were walking to the other side of the bed, an explanation was not provided. CNA “K” was then asked if Resident #101 was supposed to be a one assist with bathing and bed mobility and replied, “Always do one assist for bed bath.” When queried why they asked the Resident to hold the metal bar/bed frame under the mattress, CNA “K” responded, “That is how we always did it.” When asked if the Resident was care planned to be a one assist with bathing and bed mobility, CNA “K” stated, “I didn’t know (Resident #101) was a two assist until after (the fall).” When queried how they know what level of assistance residents require for care, CNA “K” indicated it is in their care plan/Kardex (care guide). CNA “K” was then asked if they reviewed Resident #101’s care plan/Kardex before providing care on 6/24/25 and stated, “I did afterwards and saw (Resident #101) was supposed to be a 2 (assist).” When queried why they did not review the care plan/Kardex prior to providing care, CNA “K” stated, “I just did what I was trained to do by another CNA.” An interview was completed with CNA “P” on 7/23/25 at 10:25 AM. When queried regarding Resident #101’s upper extremity strength, CNA “P” replied, “Has good days and bad days” and indicated the Resident’s ability fluctuates. CNA “P” was asked if they were working on 6/24/25 when Resident #101 fell and revealed they were but were not assigned to Resident #101’s area. When queried regarding the level of staff assistance Resident #101 required for bathing and bed mobility prior to the fall, CNA “P” stated, “(Resident #101) has always been a two (assist).” A review of CNA “K’s” employee file and disciplinary actions revealed an Employee Coaching Form dated 7/16/25. The Employee Coaching Form specified, “The following employee is in violation of the following rule: Did not check residents Kardex (care plan guide) before providing care. Description of Incident: Employee was providing bed bath and did not ask for assistance…” On 7/23/25 at 2:35 PM, an interview was completed with the DON. When queried they were involved in the investigation of Resident #101’s fall on 6/24/25, the DON replied, “I knew that (the Resident) was sent out. It wasn’t brought to my attention that we were doing a bed bath with only one assist.” When asked to clarify, the DON revealed they were not immediately notified that the Resident’s fall occurred during care and that the care plan was not being followed. When asked what happened, the DON stated, “(Resident #101) was sent to one hospital and they sent them back. Then (Resident #101) was sent to a different hospital, they found a fracture and then came back over a week later.” The DON revealed they were unaware Resident #101 had suffered a fracture until they returned to the facility from the second hospital. When queried what they identified as the cause of the fall, the DON verbalized CNA “K” did not follow the Resident’s care plan and provided a bed bath with one staff when the Resident required two staff for care. When asked why two staff were not providing care, the DON stated, “(CNA “K”) admitted they didn’t check” the care plan/Kardex. A policy/procedure related to expectation for staff to review the care plan/Kardex prior to providing care was requested at this time and the DON revealed they did not know if that information would be in a policy/procedure. The DON stated, “I feel like that is common sense for them to check the Kardex.” When queried regarding CNA “K” having the Resident grab the metal bar/frame of the bed when they were turning them, the DON revealed they “have seen that before.” The DON continued, “I think it is more that (Resident #101) is grabbing for something to hold themselves when they are being turned. When queried if the Resident had been evaluated for an enabler bar, to provide them something to grab while being turned, the DON replied, “I don’t know.” When queried if they understood the concern, the DON replied, “Yes.” No further explanation was provided. Review of Hospital documentation for Resident #101 revealed the following: - 6/25/25 at 11:55 PM: “ED Provider Note… Physical Exam… Right Lower Extremity Significant tenderness to palpation of the lateral aspect of right hip… unable to move the leg at baseline… Decreased sensation from the midcalf distally… Right upper extremity… Passive range of motion is severely limited due to pain… Admit… symptomatic with right subtrochanteric hip fraction and had not achieved medical stability… Condition: Guarded…” - 6/26/25 Right Femur X-Ray: “Acute nondisplaced subtrochanteric fracture right femur… probably also chip fracture of the lesser trochanter…” Resident #101 had surgery on 6/26/25. Resident #105: Record review of Resident #105's electronic medical record progress note revealed an admission date of 6/25/2025 from the hospital setting. Medical diagnosis included: Urinary tract infection, chronic obstructive pulmonary disease, hypertension, spondylosthesis, alcohol abuse, transient ischemic attack (TIA), dementia, low back pain, metabolic encephalopathy, insomnia, retention of urine, myocardial infarction. Record review of resident #105’s previous hospital medical record dated 6/24/2025 revealed the resident was treated for pneumonia with no mention of fractured rib. Record review on 7/23/2025 of Resident #105’s ‘Incident by incident types’ of report revealed 5 (five) “Fall” incidents had occurred: 6/25/2025 at 8:30PM 6/26/2025 at 6:15AM 6/26/2025 at 8:00PM 6/28/2025 at 4:40AM 6/29/2025 at 9:40PM Record review of Resident #105’s ‘Incident report’ dated 6/28/2025 at 4:40AM revealed the nurse was alerted to the resident being on the floor next to his bed. When entering the room, the resident was back in bed. When the nurse asked the Certified Nurse Assistant (CNA) how the resident got up, the CNA stated, “He did it himself”. The nurse noted that the resident #105 stated he jumped on the floor and that he wants his Pepsi. No injuries observed at the time of incident. Record review of Resident #105’s nursing progress note dated 6/28/2025 at 5:01AM revealed: Nurse alerted to resident being on the floor next to his bed. When the writer entered the room the resident was back in bed. When writer asked the CAN how resident got up, she stated “He did it himself”. The resident stated he jumped on the floor and that he wanted his Pepsi. Vital signs taken, skin assessed and intact, Range of Motion (rom) assessed and present in all extremities, denies pain, neuro (checks) initiated physician notified, family to be notified in the morning, management notified. Record review of the next nursing progress note dated 6/28/2025 at 9:49AM revealed: Interdisciplinary team met to review fall. Resident was observed on the floor by the Certified Nurse Assistant (CNA) and while the nurse was coming for assessment resident got himself u and got back in bed. Resident was sent out to the hospital, and he noted to have a rib fracture and Urinary Tract Infection (UTI) returned from ER with antibiotic. Resident stated he was trying to get his Pepsi. Intervention will be to keep drinks on side table within reach to reduce the risk of falls. Record review of Resident #105’s hospital emergency room record dated 6/28/2025 revealed resident was sent for a fall with rapid heart rate. emergency room work up revealed a Urinary Tract Infection (UTI) and right 7th rib fracture without any callus and likely an acute fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00153516. Based on observation, interview and record review, the facility failed to prevent two (2) Stage II (blisters) pressure injuries for one resident (Resident #102) of 3 residents reviewed for pressure ulcers, resulting in two (2) upper left shoulder, Stage II pressure ulcers, pain/discomfort, wound treatments and the likelihood for a decline in overall health. Findings include: A Stage II pressure ulcer is partial-thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents as an abrasion, shallow center or blister. High risk residents (immobile, bed bound) should be assessed weekly, when a condition, change or as needed and preventive measures should be in place including pressure relieving devices, position changes, and dietary supplements. National Pressure Ulcer Advisory Panel (NPIAP). Resident #102: In an observation on 6/13/25 at 9:50 AM, Resident #102 was observed seated up in reclining Broda chair in the main area in front of nursing station. Dressed in red checked Pajama bottoms and a tan sweatshirt with pink sock on left foot and a gauze batting wrapped with an Ace bandage on the right foot/leg. Resident #102 appeared to be sleeping and did not respond to her name. Observed position to be leaning to the right side of chair with pillow between her legs curled in a fetal position with knees pulled upward with the right heel positioned in the leg extension crack between the blue padding of chair leg rest. An observation on 6/13/25 at 10:00 AM of room [ROOM NUMBER], revealed a clean room free of odors, bilateral fall mats on each side of bed, and a private bathroom, which was clean with no odors. No dirty laundry located in room. Observation in the closet revealed a white laundry basket with a few items were noted with no odors. Observation of upper shelves noted 2 Tide laundry pod packages noted on shelf in closet. Clothing Items hanging up, and a large round blue laundry bin noted in closet with clean clothes, no odors. Mattress on bed with contour edges, reviewed sheets to be clean with mint green lift pad on bed, bed is made. Record review of Resident #102's Care plans revealed Resident #102 had a history of falls, behaviors related to dementia, and risk for alteration in skin. Review of the care plan revealed 'Risk for Alteration of Skin' care plan was last updated on 2/8/2025 with interventions of: Pressure reduction mattress, apply pressure reduction cushion when up in wheelchair, remind/assist resident to reposition frequently, provide peri-care after each incontinent episode and apply barrier cream, discuss plan of care with responsible party and notify MD (physician) of any significant changes. There were no new added interventions related to the development of left should pressure ulcer injuries. Observation on 6/13/2025 at 1:05 PM in the facility's main dining room of Resident #102 showed the resident seated in the same position of leaning to the right of Broda chair with knees drawn upward with right heel in the crack of the wheelchair footrest cushion, no change of position noted since early morning observation. Certified Nurse Assistant (CNA) H was seated at a table with 3 residents, Resident #102 and 2 others, feeding all residents. Resident #102's plate had: pureed fish, mashed potatoes, a vanilla pudding cup, coffee, and fruit punch. Record review of Resident #102's June 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed: Wound care left outer shoulder- cleanse with wound cleanser, apply xeroform and cover with border gauze daily and as needed every day-shift. The dressings started on 6/6/2025 and were signed out by nursing staff as done daily through 6/12/2025. Observation and interview was conducted on 6/13/2025 at 2:45 PM with Licensed Practical Nurse (LPN) F of Resident #102's left upper shoulder skin areas. LPN F stated that Resident #102 has contractures of the left arm, and the nurse had to undress/remove the shirt sleeve to get access. Left upper arm/shoulder dressing observed dated 6/9/2025 (4 days prior), Dressing removed, and the first left shoulder pressure wound was cleansed and measured 3.5 cm length X 3.0 cm wide no depth measured. Observation of the second left should pressure ulcer area was cleansed and measured 2.0 cm length X 2.0 cm in width, no depth measured. LPN F stated that the pressure areas were noticed after the right leg fractures and the resident was staying in bed more, the 2 weeks after the fractures. Observation of wound care: areas cleansed with wound cleaner, patted dry with gauze, xeroform Vaseline gauze treatment applied to wounds, covered with foam border dressing, and dated by LPN F 6/13/2025. In an interview and record review on 6/13/2025 at 3:50 PM with the Director of Nursing (DON), the State surveyor requested all pressure ulcer/skin policies of the facility. DON stated that the left shoulder wounds started last week on 6/5/2025 from blisters or denuded skin. DON acknowledged that there were two (2) separate wound sites on the left should area. The DON stated that he had just done wound measurements today, after the state surveyor had done the wound care treatment observation and measurements. The DON stated that he has no photos of the wounds nor any measurements prior to the state surveyor observation. Record review with DON of Resident #102's wound/skin tab in the electronic medical record revealed that on 6/5/2025 the left shoulder wound was noted as blister (8 days prior to interview). Record review of Resident #102's physician progress notes by the DON revealed that there were no doctor's progress notes since 3/11/2025 which were by a nurse practitioner. There were no notes about the right leg fractured tibia & fibula, nor the left shoulder pressure ulcer/wounds by physician. Record review of the nursing progress notes revealed a left shoulder note on 6/5/2025 at 4:00 PM the date of discovery and no other skin note related to pressure injuries of the left shoulder, no measurements and no photos. Record review of the facility 'Pressure Injury Treatment Guidelines' policy, dated 12/2019, revealed treatment guidelines for at risk individuals included: Activity/Mobility: assess resident for degree of physical activity. Provide appropriate pressure redistribution devices, teach resident to weight shift if appropriate, and ensure proper body alignment. Residents will be repositioned with consideration to the individual's level of activity, mobility and ability to independently reposition. Reposition/shifts the body position, and/or encourage repositioning as needed per the individualized plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake Numbers MI00149500 and MI00149604. Based on observation, interview and record review, the facility failed to implement appropriate interventions timely to prevent a pressure ulcer for one resident (Resident #1) of three residents reviewed for pressure ulcers, resulting in an unstageable coccyx pressure injury (full-thickness pressure injury where the base of the wound is covered by a layer of dead tissue, making it impossible to determine the stage of the injury), pressure ulcer infection and hospitalization. Findings include: Resident #1: On 1/17/25, at 12:30 PM, a record review of Resident #1's electronic medical record revealed an admission on [DATE] with diagnoses that included aftercare following surgery on the circulatory system, need for assistance with personal care and Dysphagia. According to the Minimum Data Set assessment on admission, Resident #1 required 2-person assistance for bed mobility and had moderate cognitive impairment. A review of the Braden Scale admission Date: 12/16/2024 revealed a Score of 16.0. A review of Minimum Data Set assessment Section M . Signed . Fri [DATE] . Is this resident at risk of developing pressure ulcers/injuries? . Yes . Does this resident have one or more unhealed pressure ulcers/injuries? . No . A review of WOUND ASSESSMENT DETAILS REPORT Coccyx Assessment Date 01/06/2025 3:49 PM . Facility Acquired . Date Identified 01/02/2025 . Clinical Stage Partial Thickness . Tissue Types Deep Maroon=10%, Slough Loosely Adherent=40%, Necrotic Soft, Adherent=50% . Exudate Amount - Moderate Type - Serosanguinous . Pain Scale 8 Odor Yes Signs of Infection Present Yes . Size (centimeters) 12.00 x 14.00 x Unknown (L x W x D) . A review of the Collection Date: 01/05/2025 . Culture Source Wound Heavy Growth Proteus Penneri . Heavy Growth Escherichia Coli . A review of the progress note 1/8/2025 02:10 (2:00 AM) . Observe guest skin clammy and sweaty . Guest was shaking and had chills. When conversing with guest, guest could not converse back appropriately due to confusion . DR gave order to send to hospital . A review of the Focus Potential/At Risk for alteration in skin integrity due to risk factors associated with impaired mobility. Date Initiated: 12/16/2024 Created on: 12/16/2024 Revision on: 12/16/2024 Goal Resident will have no complication thru next review date Date Initiated: 12/16/2024 Created on: 12/16/2024 . Interventions Pressure redistribution mattress Date Initiated: 12/16/2024 . Apply pressure redistribution cushion when up in chair/wheelchair Date Initiated: 12/16/2024 . Remind/Assist resident to reposition frequently Date Initiated: 12/16/2024 . Float heels off mattress Date Initiated: 12/16/2024 . Encourage ambulation/mobility Date Initiated: 12/16/2024 . Provide peri-care after each incontinent episode and apply barrier cream Date Initiated: 12/16/2024 . Check skin daily Date Initiated: 12/16/2024 . Keep linens dry and wrinkle free Date Initiated: 12/16/2024 . A review of the Focus Alteration in skin integrity - Resident has Pressure Injury. site coccyx. factors that may inhibit wound healing: Immobility, Incontinence. AEB: Wound is considered unavoidable at this time due to poor intake and refusal to reposition. Date Initiated: 01/03/2025 Created on: 01/03/2025 . Revision on: 01/03/2025 Goal Resident will be free from complications thru next review date. Date Initiated: 01/03/2025 . Interventions Administer pain medication as ordered Date Initiated: 01/03/2025 . 01/03/2025 Apply specialty mattress when in bed. Date Initiated: 01/03/2025 . 01/03/2025 Apply pressure redistribution cushion when up in a chair/wheelchair. Date Initiated: 01/03/2025 . Reposition/Shift weight at frequent intervals to resident's comfort. Date Initiated: 01/03/2025 . Assess and document wound status weekly and PRN (as needed) Date Initiated: 01/03/2025 . Daily Skin checks during care. Date Initiated: 01/03/2025 . Discuss plan of care with resident and responsible party. Date Initiated: 01/03/2025 . Monitor for infection: Peri-wound swelling - Exposed bone - Pressure wound deterioration. Date Initiated: 01/03/2025 . Notify MD and responsible party of any significant change in wound status. Date Initiated: 01/03/2025 . Peri-care after each incontinent episode and apply barrier cream. Date Initiated: 01/03/2025 . Treat as ordered per MD. Date Initiated: 01/03/2025 . A review of the progress notes prior to pressure ulcer development on 1/2/2025 revealed no mention of Resident #1 refusing to be repositioned in bed. On 1/21/25, at 2:21 PM, a record review along with the Administrator of Resident #1's record was conducted. The administrator offered, the wound went bad real fast and the day he went to the hospital he was supposed to sign onto hospice. The administrator offered, the resident quit eating, they added supplements and assisted with meals to aide with the weight loss. A record review of the admission assessment revealed no coccyx wound on admission. The administrator offered that the resident had malnutrition and had lost weight in the hospital before admitting to the facility. The administrator was asked what interventions they placed to reduce the risk of development of pressure ulcers and the Administrator offered, a pressure reduction mattress. The Administrator was asked with Resident #1's history of weight loss, recent Heart surgery and illnesses why they wouldn't implement all interventions, such as an air mattress on admission and the Administrator offered, absolutely, I agree. A review of the facility provided Skin Management Program DATE REVIEWED 7/24 revealed . Residents with wound and /or pressure injury and those at risk for skin compromise are identified, assessed, and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes . A Braden Scale will be completed upon admission . Appropriate preventative measures will be implemented on residents identified at risk (a score of 18 or less on the Braden Scale) and the interventions documented on the care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #155: On 7/2023 at approximately 3:00 PM, a review was completed of Resident #155 medical records, and it revealed the resident admitted to the facility on [DATE] after a knee replacement. She also has diagnoses of Hyperlipidemia, Carpal Tunnel, Abnormalities of Gait and Mobility and Muscle Weakness. Further review of Resident #155's records revealed the following: Progress Notes: 4/20/2023 at 18:30: Guest arrived to room [ROOM NUMBER]-2 at 1830 via private auto. Guest admitted to hospital and underwent a Total R (right) knee replacement .Guest is extensive assist for transfers, WBAT (weight baring as tolerated) to RLE (right lower extremity). Meriplex dressing in place and per orders from hospital dressing to stay in place post-op 72 hours .Underneath dressing are staples that are to stay in place and will be removed at follow up appointment . 4/21/2023 02:30: Guest observed sitting on her buttocks on the bathroom floor with her back to the door. She was positioned next to the toilet (between sink and toilet). Blood and guest's tooth noted on the bathroom floor next to her. Right leg was twisted a little next to the leg of the high rise seat of the toilet. Guest self transferred to toile, when finished she stood up and when standing her foot got caught on high rise where she lost balance and fell face forward . 4/21/2023 10:24: IDT (Interdisciplinary Team) met to review fall. Guest had unwitnessed fall. Guest was observed on the bathroom floor. Guest was noted to have taken her self to the bathroom she was observed on the floor with her knee twisted and blood on the floor with her toot (tooth) out. Tooth was placed in a glass of milk. Guest was assessed and DR call with order to send her out to the hospital for assessment . At time of fall CNA was in the room assisting bed 2 asked had asked for help CNA stated she would be able to help her in just a few minutes as she finished care on bed 2 . Guest choose to not wait and took self to bathroom. Guest was able to describe how fall happened and how she took her self to the bathroom . 4/22/2023 11:20: .Resident c/o pain and swelling to right hand. Resident had a fall recently and she states her hand was not x-rayed. She reports pain and difficulty closing her right hand. Nurse has paged on-call provider and is waiting a call back. Will request a STAT x-ray. Resident also damaged her lips during aforementioned fall and her lips are scraped, bruised, and scabbing . 4/24/2023 07:33: Immobilizer in place ( right knee) . emergency room Records: .patient is [AGE] year old female who is post-op day 1 from right knee replacement who presents to the emergency department via EMS after fall. Per patient was attempted to use a commode which was too high for her and in doing so urinated on the floor. She ultimately slipped on this and fell striking her head on the ground as well as hurting her knee which was operated on yesterday. She did lose the front right incisor which was an implant .place the patient in knee immobilizer .follow up with oral surgeon for management of her tooth fracture . Incident & Accident Report: 4/21/2023 at 2:30 AM: Guest observed sitting on her buttocks on the bathroom floor with her back to the door. She was positioned next to the toilet (between sink and toilet). Blood and guest's tooth noted on the bathroom floor next to her. Right leg was twisted a little next to the legs of the high rise seat of the toilet. Assigned CNA (Certified Nursing Assistant) was in room helping 307-2. Guest states that she was unable to wait for assigned CNA to help so she got up and self-transferred to bathroom. Guest finished using bathroom, she stood up and when standing her food must have gotten caught on high rise where she lost balance and fell face forward .No injuries observed post incident .CNA yelled down 300 hall, writer and other nurse ran down the hall to 307. Upon entering resident noted sitting on the floor in the bathroom on her buttocks facing toward the toilet. Residents' mouth was bleeding, resident states I knocked my tooth out. Cold cloth given to resident to hold to mouth to stop the bleeding .Writer noted residents right knee and calf were not in alignment with body Resident states, I can't feel pain from my leg, just my face .Right leg (knee) appeared to be twisted . I just took he roommate 307-2 to the bathroom. The curtain was closed. As I was taking care of 307-2 back to the bed and helping 307-1 said I have to pee. I then said, Hold on one minute I am almost done and I will be over to help you. I then heard her say, I can't wait I gotta pee. I then said , I am almost done and I will be right here. I finished up with 307-2 and I heard a yell from the bathroom. I went and seen that she was on the floor. I went and got the nurses. It can be noted the sequence of events differ provided in facility documents differ from hospital documentation. Due to staff inaction Resident #155 fell in the bathroom, reinjured her knee that was replaced 1 day ago and dislodged her tooth. Resident #155's fall was avoidable. On 7/21/ 2023 at 9:17 AM, Human Resource file of Nurse J was reviewed in the presence of Human Resource Director V. There was a 1:1 coaching dated for 5/19/2023, both this writer and Human Director V were under the impression the disciplinary action was not related to Resident #155's fall on 4/21/2023 given it was a month later. The 1:1 Coaching stated, One to one coaching was held with the above listed employee covering the following topics: 1. Check list not completed for falls. 2. Note not in chart completed late after verbal cueing to complete. 3. Reported by guest she requested assistance to bathroom assistance was not offered and reciprocated. Went to break guest fell. You must attend to guest needs prior to break. There is a handwritten response from Nurse J on the form that stated, Guest never ask for me to help her go to bathroom guest had already taken herself and was getting back in bed. During the investigation attempts were made to contact CNA Y that was in the room during Resident #155's fall to no avail. CNA Y was no longer employed at the facility and the number they had for her was disconnected. On 7/21/23 at 03:21 PM, an interview was conducted with the DON (Director of Nursing) regarding Resident #155's fall on 4/21/2023. The DON explained a full investigation was completed of the fall and Nurse J was disciplined as she failed to complete the appropriate assessments and documentation after the falls. Additionally, Resident #155 asked Nurse J for assistance going to the bathroom (prior to CNA Y entering the room to assist 307-2) and instead of attending to the resident's need Nurse J went to the break and then the resident fell. The DON stated Resident #155 was cognitively intact and described Nurse J to them in detail. The DON was queried if CNA Y was interviewed, and the DON stated she was, but they are still looking for the full investigation. The DON was asked exactly what care CNA Y was providing to 307-2 and the DON did not have a response. It was explained this is an important detail because dependent on what type of care CNA Y was doing was it plausible and/or safe to stop and assist Resident #155 given she just admitted after a knee replacement. It also leaves to question if CNA Y knew Resident #155 required toileting/walking assistance why did she not enable the call light? Resident #155 was able to get up from her bed, walk to the bathroom, use the restroom, stood up and then fell and all on a knee that was replaced days ago. It can be noted there was more the CNA could have done to assist timelier or request assistance for Resident #155, rather than continuing care on 307-2 with no attempt at intervention. The DON was queried why Nurse J was disciplined for her inaction almost a month later and DON reported there was delay in completion of the investigation as she was off work and it took some time to investigate all staff involved. The DON acknowledged the concern with the incomplete and timely fall investigation, thorough root cause analysis of staff failures and appropriate trainings to prevent another like incident. On 07/21/23 at 04:05 PM, the Administrator shared there was a grievance completed as Resident #155's family requested the facility pay for the tooth that was dislodged during the fall. The Administrator stated it was found Nurse J observed Resident #155 get out the bed and walk toward the bathroom but did not intervene. Nurse J asserted Resident #155 was walking fine and did not ask for any assistance. At the conclusion of the survey the investigation into Resident #155's fall was not located by facility management. Based on observation, interview and record review, the facility failed to provide supervision to prevent falls/accidents for five residents (Resident #5, Resident #6, Resident #37, Resident #155, Resident #203,), resulting in injuries, pain, and hospitalizations. Findings include: Record review of the facility provided CMS 672 upon entrance to the survey on 7/19/2023 revealed a resident census of 54. record review of facility provided CMS 802 revealed 26 out of 54 Residents were identified as having a fall (F), fall with injury (FI), or fall with major injury (FMI). 26 Residents divided by total 54 Residents equals 48% fall rate. Record review of facility 'Safety and Supervision of Residents' policy dated 9/2022 revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Monitoring the effectiveness of interventions shall include the following: (a.) Ensuring that interventions are implemented correctly and consistently. (b.) Evaluating the effectiveness of interventions. (c.) Modifying or replacing interventions as needed. (d.) Evaluating the effectiveness of new or revised interventions. Systems approach to safety: (1.) The facility-oriented and resident oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual residents risk factors, and then adjusts interventions accordingly. (2.) Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. (3.) The type and frequency of resident supervision may vary among residents and over time for the same resident. for example, resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition. Record review of the facility 'Stand up for Falls (Falls Management and Prevention Program Guidelines) policy, dated 06/2021, revealed it is the intent of the facility to provide residents with assistance and supervision to minimize the risk of falls and fall related injuries. Resident reviews: Resident #5: Record review of Resident #5's Minimum Data Set (MDS) quarterly dated 7/5/2023 elderly female with a Brief Interview of Mental Status (BIMS) score of 5 out of 15, cognitively impaired. Medical diagnosis of medically complex condition, coronary artery disease, hypertension, Alzheimer's disease, non-Alzheimer dementia, anxiety, depression, psychotic disorder. Review of Section G: Functional Status noted transfers, ambulating, dressing and toileting with one person assist. Section J: falls noted 2 falls with no injuries during the assessment quarter. Record review of Resident #5's six month look back revealed falls on: Fall incident reports: -On 1/6/2023 at 3:30PM Resident #5 was observed on floor in her room. No injury was observed. Resident #5 was re-educated on call light. No witnesses were noted. No Neuro sheet was provided by facility. -On 2/23/2023 at 2:57 PM Resident #5 was found on the bathroom floor. Witness statement noted resident was paced on the toilet with call light in reach and left alone prior to fall. Resident #5 was noted to state that she hit her head. Cause was noted as resident is impulsive. Neuro sheet completed. -On 2/26/2023 at 2:57 PM Resident #5 was found on floor next to recliner chair in room. No witnesses to fall noted. Neuro check sheet incomplete. -On 3/31/2023 at 6:30 AM Resident #5 was found on the floor in room next to chair. Fall report noted staff rounded at 5:50 AM. Incomplete Neuro check sheet noted. -On 4/6/2023 at 8:00 PM Resident #5 was heard yelling 'Help me, Help me' by staff. Resident #5 found on floor laying on her back in room. No witnesses noted to fall note. Neuro check sheet completed. -On 4/15/2023 at 1:30 PM Resident #5 was found sitting on bathroom floor. No witnesses noted on fall report. Neuro check sheet complete. -On 5/15/2023 at 3:10 PM Resident #5 call light was ringing and when staff entered room Resident #5 was found on the floor in room. No witnesses noted on fall report. -On 5/26/2023 at 9:45 AM Resident #5 was heard yelling for help by housekeeping staff. The housekeeper enters the room and lowered the resident to the floor. -On 5/29/2023 at 4:53 PM Resident #5-bathroom call light was ringing. Resident #5 was found standing the bathroom holding onto the rails. Resident #5 went to sit in wheelchair and the wheelchair moved from behind her (breaks not set). Observation on 07/21/23 at 08:13 AM of Resident #5 was observed by surveyor to be seated up in her recliner in room with no call light, call light located across room tied to the wheelchair near the restroom. The surveyor stepped into the hallway and on 07/21/23 08:15 AM Licensed Practical Nurse (LPN) E was brought into the room. Resident #5 was observed to be standing up in front of the recliner at time of nurse entry to fix the call light situation. Resident #5 states no one talks to me, they don't do nothing or say anything to me. Call light taken from wheelchair and clipped it to the recliner by nurse E. Resident #6: Record review of Resident #6's Minimum Data Set (MDS) quarterly dated 5/26/2023 elderly female with a Brief Interview of Mental status (BIMs) score of 2 out of 15, severely cognitively impaired. Medical diagnosis of medically complex condition, coronary artery disease, hypertension, Alzheimer's disease, non-Alzheimer dementia, Parkinson's disease, traumatic brain injury, anxiety, depression, psychotic disorder, syncope and collapse, muscle weakness, dysphagia, repeat falls. Review of Section G: Functional Status noted transfer with extensive assist of two people, ambulating did not occur, dressing, eating and toileting with extensive assist of one person. Bathing of total assist of one person. Section J: falls noted 2 falls with no injuries during the assessment quarter. Record review on 07/19/23 at 02:56 PM of Resident #6's progress notes revealed falls. Surveyor requested accident incident reports for 6 months. Interview and record review on 07/20/23 at 01:54 PM with the Director of Nursing (DON) of Resident #6's fall timeline for falls. Number of falls? - 6-month review of falls, 10 falls per fall report presented by Director of Nursing. Record review of Resident #6's nine month look back revealed falls on: Fall incident reports: -On 8/22/2022 at 7:00 AM Resident #6 found sitting on floor in doorway to room facing hallway. Resident #6 was noted incontinent of urine and had fresh nosebleed and hematoma noted to left eye and top of left head. Hematoma noted to appear dark blue/purple. No witnesses noted on fall report. Later that day resident went to pacemaker appointment with family member. -On 8/22/2022 at 2:00 PM Resident #6 found lying face down on left side of bed. Assisted back to bed, pressure applied to bloody nose. Resident #6 was sent to emergency room for evaluation. Resident #6 was admitted for subarachnoid hemorrhage. -On 8/31/2022 at 12:00 PM Resident #6 found on floor in front of closet. Abrasion noted to right eye noted. No witnesses found. -On 9/7/2022 at 9:05 PM Resident #6 found on floor at bedside. Resident #6 hit head on right side of bedside table bottom. Noted blood to right side of head, right ear split in half and goose egg on top of head with hematoma, right top of hand with hematoma noted. No witnesses noted. -On 9/9/2022 at 4:45 PM Resident #6 was found on the floor in room with right scapula/shoulder injury noted. No witnesses noted. [NAME] placed at bedside. Right shoulder X-ray negative for fracture. -On 10/4/2022 at 4:30 PM Resident #6 found on floor on right side of bed. Laceration to right side of head. Resident #6 was sent to emergency room for evaluation. No witnesses noted on fall report. Floor matt placed on left side of bed. -On 12/4/2022 at 10:15 PM Resident #6 was found in doorway on bottom. Fall matt in place. Resident was not wearing gripper socks at time of the fall. Redness to bottom and back noted. No witnesses noted on fall report. Record review of undated neurological checks were incomplete. -On 12/17/2022 at 11:36 AM Resident #6 found on floor in dining room. Fall from wheelchair with breaks unlocked. No witnesses noted on fall report. Current Broda chair large. Record review of dated 12/17/2023 neurological checks were incomplete. -On 1/18/2023 at 11;15 AM Resident #6 found lying face down on floor matt on right side of bed. Fall report noted Resident #6 was laid down at 9:00 PM and found on 11:15 PM by certified Nurse assistant. -On 1/22/2023 at 4:00 PM Resident #6 was noted the Certified Nurse Assistant (CNA) informed nurse she saw Resident #6 fall as she came out of the bathroom while getting gloves to change her brief. Fall report did not list the name of the certified nursing assistant. -On 2/13/2023 at 11:30 PM Resident #6 was found on floor laying on her back on mat at bedside. Certified Nurse Assistant (CNA) was noted to be walking down hall when they heard Resident #6 yell out Help. CNA was noted to see Resident approximately two hours prior. -On 2/16/2023 at 4:00PM Resident #6 was found on dining room floor. Fall from wheelchair/Broda. Resident #6 was noted to have impulsiveness and poor safety awareness. -On 2/24/2023 at 7:15 PM Resident #6 was observed by other resident to slip to floor in front of wheelchair in the dining room. Other resident was noted to state Resident #6 stood up from the wheelchair and fell to the floor. -On 2/27/2023 at 3:37 PM nurse walked past Resident #6's room and observed Resident #6 on floor at bedside. Scrape/abrasion noted to lower back of 4cm X 1.5cm. No witnesses noted on fall report. -On 2/27/2023 at 7:00 PM Resident #6 was found on the floor at the end of the 200 hall. No witnesses noted on fall report. Record review of dated 2/27/2023 neurological checks noted incomplete neuro checks. -On 3/30/2023 at 6:40 PM resident #6 was found on floor in dining room in front of wheelchair. Abrasion noted to left trochanter. Witnesses did not see Resident #6's fall. Record review of dated neurological checks noted pupils to not be equal. -On 4/11/2023 at 8:00 PM nurse was passing bedtime medications on 200 hall, when Resident #6's call light rang. Upon entering room nurse found Resident #6 lying on the floor. No witnesses were noted on the fall report. Record review of undated neurological checks noted pupils to not be equal. -On 6/10/2023 at 11:05 PM Resident #6 was found on floor half in bed and half out of bed. Abrasion to forehead noted and dressing applied. No witnesses were noted on the fall report. Resident #37: Record review of Resident #37's electronic medical record profile noted an elderly female with cognitive impairment. Medical list diagnosis of muscle weakness, unsteady on feet, abnormality of gait and mobility, lack of coordination, diabetes, disorder of bone density, nontraumatic subdural hemorrhage, fracture of right radius, neuromuscular dysfunction, fracture of pelvis and impulsiveness. In an interview on 07/19/23 at 12:12 PM with a family member revealed that Resident #37's falls started in March 2023. Resident #37 had a fell and dislocated the pinky finger and was sent to the emergency room and went back to facility. Resident #37 fell again in April 2023, and fractured her hip, had surgery at hospital, and was sent back to the facility. In May 2023 she (Resident #37) was found in the bathroom on floor with fractured wrist and was sent back to the hospital. The hospital found hematoma to head, from the April 2023 fall. They sent her back to the facility on Hospice and they come weekly. She had a cast on her wrist for 8 weeks and it was removed 2 weeks ago. The family member was at the facility on Monday, and they put the call light on and waited a long time, then walked down to the nursing station to get help. In an interview on 07/20/23 at 09:22 AM with Resident #37 was lying in bed. Resident #37 stated that she did fall in here (at facility). I fell and I get heck from my daughter. Surveyor observed large purple hematoma to right forearm area. Resident #37 is able to move the arm. Record review of Resident #37's six month look back revealed falls with fractures on: Fall incident reports: -On 3/23/2023 at 12:03 PM Resident #37 was noted to stand up from chair and fell down while staff in room. Resident #37 was noted to hit her head on the bottom of bedside table (metal roller ball under table). Laceration to left hand, bruise to right lateral eyebrow, left pinky finger is bruised and swollen with cut on pinky finger. The left pinky finger was noted to not be in the anatomical position. In an interview on 07/21/23 at 01:04 PM with Certified Nurse Assistant (CNA) K revealed that the CNA had Resident #37 that day. CNA K stated that she was in the bathroom getting some towels to clean her up. I was cleaning her up to put on clean clothes for the day. Resident #37 stood up and lost her balance and fell. She hit her head on the metal tray table bar under the table. I pulled the emergency cord, no one came. CNA K ran to the nurse's station and told the nurse. The nurse did come to the room with me. When we got to the room Resident #37 was sitting up on the side of the bed. Resident #37's pinky finger was broken, sticking out to side, not natural. Resident #37 just sat there, and we sent her to the emergency room, for the pinky finger. She came back that day. -On 4/23/2023 at 11:01 AM Resident #37 was found on floor in bathroom with skin tear to right elbow of 2.3cm, area cleansed and steri strips applied. Resident #37 was noted to guard right lateral lower extremity. -Record review of Resident #37's hospital surgical documentation dated 4/25/2023 noted right intertrochanter fracture after a fall. -On 5/5/2023 at 7:00 PM Resident #37 was found on the floor in front of closet in room. Hematoma noted to right side of forehead, skin tear to right elbow measuring 2.5cm, area cleansed and steri strips applied. Resident #37 was noted to be guarding right swollen wrist. Witnesses were noted to not have seen Resident #37 fall. -Record review of Resident #37's hospital discharge documentation dated 5/8/2023 revealed principal diagnosis for discharge: (1.) Traumatic subdural hematoma. (2.) Distal radial fracture (wrist). (3.) Elevated troponin. (4.) Diabetes mellitus. (5.) Coronary artery disease. (6.) Hypertension. (7.) Hypothyroidism. (8.) Hyperlipidemia. (9.) Dementia. (10.) Cerebral hyponatremia. (11.) Frequent falls. In an interview and record review on 07/20/23 at 01:32 PM with Director of Nursing (DON) typed up a timeline of Resident #37's falls, dislocated pinky finger from fall on 3/23/23, then on 4/23/2023 at 11:01AM fall with fractured hip in bathroom, sent to hospital had repair, came back. The next fall was on 5/5/2023 in the bathroom, fractured wrist on 5/07/20/23 01:41 PM from fall. She did have a subdural hematoma (brain bleed also). In an observation and interview on 07/21/23 at 11:07 AM of Resident #37 with the Assistant Director of Nursing (ADON) L observed right forearm, with dark purple bruise noted. ADON L stated that she did not measure the bruised area but will. Observation of right forearm bruise measurements revealed 12.5 cm length X 16cm wide, around the arm. ADON L stated that the facility did not know what the hematoma came from. we just don't know. ADON L will investigate the bruise. She did have a wrist cast but it was removed 2-3 weeks ago. Resident #203: Record review of Resident #203's Minimum Data Set (MDS) readmission assessment dated [DATE] elderly female with a Brief Interview of Mental status (BIMs) score of 3 out of 15, severely cognitively impaired. Medical diagnosis of medically complex condition, anemia, hypertension, renal failure, non-Alzheimer dementia, depression, unsteadiness on feet, muscle weakness, abnormalities of gait and mobility, lack of coordination and difficulty walking. Review of Section G: Functional Status noted bed mobility with extensive assist of two people, transfers with total dependence with assist of two people, ambulating did not occur, dressing with extensive assist of two people and toileting with total dependence with two people assist. Record review of Resident #203's nine month look back revealed falls on: Fall incident reports: -On 9/21/2022 at 1:00 PM resident #203 was found the floor by housekeeper. No witnesses were noted on fall report. Care plan updated to lay resident down after meals. -On 11/16/2022 at 9:30 AM Resident #203 was found on the floor in hallway by her room. Resident #203 was last seen (no time given) up in wheelchair in hallway. Care plan update to assist resident as needed. -On 12/6/2022 at 8:30 PM Resident #203 was heard yelling Help. Resident #203 was found on floor outside of bathroom. Resident #203 was noted to be seen approximately one-hour prior self-propelling in wheelchair in hallway. No new orders for care plan noted on fall report. -On 12/26/2022 at 2;15 PM Resident #203 was found on floor at bedside. Red area of 1cm noted to mid-back area. No witnesses noted on fall report. Care plan update to encourage resident to lay down after lunch. -On 1/22/2023 at 9:10 PM Resident #203 was found on floor in front of her doorway. No witnesses were noted on the fall report. Care plan to keep wheelchair on left side of bed. -On 2/14/2023 at 7:30 PM Resident #203 was found on floor in room [ROOM NUMBER] other resident's room. Resident was heard yelling Help me. No care plan updates found. -On 2/21/2023 at 8:30 AM Resident #203 was found sitting upright on buttocks on left side of bed with wheelchair behind resident to the left of her. Witness statements noted staff did not see what had occurred. No care plan update found. -On 3/15/2023 at 7:10 PM Resident #203 found on floor laying on her right side by room [ROOM NUMBER]. Injury of skin tear to right elbow, area cleansed and steri strips applied. Witness statement noted another resident came to nursing station notified staff that Resident #203 was on the floor by her room. No care plan update found on fall report. Hospital consultation note dated 4/9/2023 revealed (Resident #203) suffered a sub capital fracture around March 19th, 2023, and had (hip surgery) for bipolar hemiarthroplasty inserted. Resident #203 was admitted on [DATE] through the emergency room with infection plus fracture of the greater trochanter of her right hip. Plan to culture wound, begin antibiotic treatment, surgery for debridement to get rid of the infection plus antibiotic spacer.