**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #2573641Based on interview and record review the facility failed to timely assess, treat, notify the physician, and facilitate a transfer to the emergency room after an acute change of condition for one resident (R905), of three residents reviewed for change of condition, resulting in a transfer to the emergency room with a diagnosis of a heart attack requiring surgical intervention. Findings include: On [DATE] at 9:45 AM, a phone call was placed to the complainant, and they reported the facility failed to appropriately treat R905 for signs and symptoms of a heart attack. They said R905 requested to go to the hospital when they experienced chest pain, but the facility did not send them in a timely manner. When R905 got to the hospital it was discovered they suffered a massive heart attack requiring surgical intervention. They went on to say R905 was placed in the intensive care unit but was alert and talking to them postoperatively, however; after the surgery R905 suffered cardiac arrest and expired.On [DATE] at 10:05 AM, a review of R905's closed clinical record was conducted and revealed they admitted to the facility on [DATE] with diagnoses that included: heart disease, diabetes, pneumonia, and major depressive disorder. R905's most recent Minimum Data Set assessment indicated they had intact cognition.A review of R902's progress notes was conducted and revealed the following:A note entered into the record by Nurse ‘B' on [DATE] at 2:52 AM that read, Resident with complaint of chest pain. Nitro given x2 with no relief .Tylenol for generalized discomfort around 2100 (9 PM) .MD (medical doctor) called and voice message left. Resident requesting to go to hospital.A note entered into the record by Nurse ‘B' on [DATE] at 3:56 AM that read, NP (nurse practitioner) notified at 0339 (AM). Informed of above. Received order to transfer to ER (emergency room) for evaluation. 911 called at 0346 (3:46 AM).EMS (emergency medical services) arrived at 0355 (3:55 AM) and took over care. Transferred to ER at (Hospital Name) at 0406 (4:06 AM).A review of R905's documented vital signs did not indicate they were obtained at the time R905 complained of chest pain and requested a transfer to the emergency room.A review of R905's physician orders for nitroglycerin (a medication used for the treatment of chest pain) read, Give 1 tablet sublingually (under the tongue) every 5 minutes as needed for Chest Pain X 3 doses. If no relief, call MD). R905's MAR (medication administration record) was reviewed and revealed they only received one dose of the nitroglycerin, however; Nurse ‘B's documentation indicated they administered two.On [DATE] at 8:30 AM a review of a facility provided investigation from the Director of Nursing regarding the incident was conducted and read, .On [DATE] the Resident (R905).with history of coronary artery disease with past Percutaneous Coronary Intervention (a procedure to treat narrowed or blocked coronary arteries), CHF (congestive heart failure), Chronic <sic> kidney disease.was transferred to the hospital related to chest pain. The resident was admitted to the ICU status post STEMI (heart attack) with cardiac catheterization with 100% occlusion of the distal LAD (left anterior descending artery), angioplasty (a procedure to open blocked or occluded arteries) performed.Per hospital records, patient was placed on mechanical ventilation on [DATE] at 12:49 AM. On [DATE], the facility was informed the resident had coded and expired at 0526 am. Upon review of the resident's medical record at (Facility Name), it was noted the assigned nurse failed to: (1) Properly assess an acute change in condition of chest pain by not obtaining vital signs at the time of complaint. (2) Properly administer nitroglycerin.as ordered. (3) Documented 1 PRN (as needed) nitro (nitroglycerin) given on the MAR and documented 2 nitro given in a progress note. Order was for 3 nitro to be given 5 minutes apart, notify physician of ineffective after 3 doses. (4) Notify Physician in a timely manner, first dose of Nitro given at 0242 am, NP (Nurse Practitioner) documented as notified at 0339 am on [DATE]. (5) Transfer the resident to acute care setting immediately per resident request when administered nitroglycerin ineffective to relive chest pain.Nurse call 911 at 0346 am per her documentation.An interview was conducted with the Director of Nursing (DON) on [DATE] at 9:10 AM and they were asked how they identified the concern to prompt their investigation. They said they routinely reviewed resident transfers to the hospital to see if anything different could have been done and they identified concerns regarding R905's documented complaints of chest pain and Nurse ‘B's response. The DON went on to say that if the nitroglycerin had been administered properly per the physician's order (three doses, five minutes apart) and the chest pain had not resolved, the physician should have been notified and R905 should have been sent to the emergency room sooner based on timing.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: (1) Suspension of Nurse ‘B' with consultation with Human resources for further recommendations, (2) Identification of residents affected and residents with the potential to be affected, (3) Chart reviews for acute changes of condition and adherence to physician's orders, (4) Re-education for all nurses on medical emergency management, significant change of condition, notification of change, medication administration and documentation expectations, (5) Review of 24 and 72 hour reports, and (6) Audits conducted to monitor the corrective actions. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake# MI00152482 Based on observation, interview and record review, the facility failed to prevent new wounds from developing, provide wound care and complete/accurately document new skin impairments for two residents (R302 and R303) of three residents reviewed for wounds, resulting in R303's wound care not being completed per Physician's orders and R302's wounds including their right lateral hip, right heel, right toe, right lateral ankle and right lateral foot not being identified and treated in a timely manner. Findings include: On 5/15/25 a concern submitted to the State Agency was reviewed which alleged R302's wounds were not appropriately cared for and nobody knew about them. On 5/15/25 the medical record for R302 was reviewed and revealed the following: R302 was initially admitted to the facility on [DATE], discharged on 4/30/25 and had diagnoses including Peripheral Vascular Disease, Dementia and Protein-Calories Malnutrition. A review of R302's MDS (minimum data set) with an ARD (assessment reference date) of 4/10/25 revealed R302 needed assistance with facility staff. R302's cognition was documented as severely impaired. A review of R302's comprehensive plan of care revealed the following: Focus-[R302] is at risk for impaired skin integrity/pressure injury R/T (related to): weakness, incontinence, malnutrition,fragile skin. Date Initiated: 06/05/2023 .Interventions: Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 06/05/2023 .Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Date Initiated: 06/13/2023 . A review of R302 weekly skin assessment titled Total Body Skin Assessment dated 3/15/25 revealed R302 had no newly identified skin impairments. A review of R302's weekly skin assessment dated [DATE] revealed a struck out assessment that was entered in error. No further weekly Nursing skin assessments were noted in the record until 3/28/25. A review of R302's shower documentation for 3/26/25 indicated they had no skin impairments. A review of R302's weekly skin assessment dated [DATE] documented R302 had one newly identified skin impairment. A skin/wound progress note completed by the facility wound care coordinator dated 3/28/25 revealed the following: Skin/Wound Progress Note-Residents daughter came in to facility to speak with writer and view resident. Writer went in with daughter to complete and <sic> assessment, right foot dorsal/lateral/heel observed blackened, left outer ankle observed with non blanchable redness, right buttock observed with discolored edges and peeling skin, b/l (bilateral) hips are intact with preventative dressings in place A review of R302's shower documentation for 3/29/25 documented R302 had no skin impairments. A wound evaluation/assessment completed by the wound care medical provider on 4/3/25 revealed the following: Wound #1 Right, Lateral Hip is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5cm (centimeters) length x 3cm width x 0.1 cm depth, with an area of 15 sq cm (square centimeters) and a volume of 1.5 cubic cm There is a Moderate amount of serosanguineous drainage noted which has no odor. The patient reports a wound pain of level 0/10. The wound margin is undefined Wound bed has no, granulation, 100% slough; . Wound #2 Right Heel is an acute Partial Thickness Vasculitic Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5.3cm length x 2.3cm width with no measurable depth, with an area of 12.19 sq cm Wound #5 Right All toes is an acute Eschar covered Vasculitic Ulcer acquired on 04/01/2025 and has received a status of Not Healed. Initial wound encounter measurements are 4.2cm length x 1. lcm width with no measurable depth, with an area of 4.62 sq cm The wound margin is undefined Wound bed has no, granulation, 100% eschar; . Wound #6 Right, Lateral Ankle is an acute Eschar covered Vasculitic Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6cm length x 5cm width with no measurable depth* with an area of 30 sq cm The wound margin is attached to wound base Wound bed has no, granulation, 100% eschar; . Wound #7 Right, Lateral Foot is an acute Eschar covered Vasculitic Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 17cm length x 3.4cm width with no measurable depth, with an area of 57.8 sq cm The wound margin is attached to wound base Wound bed has no, granulation, 100% eschar; . A review of R302's weekly skin assessment dated [DATE] revealed R302 had no newly identified skin impairments. A review of R302's Physician orders revealed no treatment orders to treat any of R302's identified wounds previous to 3/28/25. A review of R302's treatment administration record (TAR) for March 2025 revealed no treatments were documented as being completed for R302's wounds until 3/29/25. On 5/16/25 at approximately 10:30 a.m., the DON (Director of Nursing) and Wound Care Nurse A (WCN A) were queried regarding R302's wounds all being initially identified on 3/28/25 with no documentation or treatments having been initiated prior and WCN A reported R302's wounds should have been identified earlier when they first started to develop. WCN A reported the facility has had problems with completing skin assessments on time and accurately. WCN A indicated that they should have been notified of the wounds so treatments could have been initiated and accurate documentation could have been completed and a wound consult been ordered for an evaluation by the medical Wound Care Provider. WCN A reported that in April they identified an issue with reporting changes of condition to management and were working to correct the deficiency. R303 On 5/15/25 at 10:57 AM, R303 was observed lying on their back in bed. A brief interview was conducted with the resident. Review of a complaint submitted to the State Agency (SA) documented concerns regarding the facility's care for R303 pressure wounds. Review of the medical record revealed R303 was admitted to the facility on [DATE], with diagnoses that included: Multiple sclerosis and was dependent on staff assistance for all ADLs (Activities of Daily Living). A review of the Skin & Wound Evaluation(s) revealed the resident had a Stage 4 pressure (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) wounds to the Sacrum and Left Gluteal Fold and a Stage 3 (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled edges are often present) pressure wounds to the Right Gluteal Fold and Left Gluteus Lateral. Review of the Medication and Treatment Administration Records (MAR/TAR) revealed the following: March 2025- 13 omitted treatments. April 2025- 11 omitted treatments. May 2025 (as of 5/15/25)- three omitted treatments. A review of a facility policy titled Skin Management revised 8/14/2024, documented in part . Resident with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing . On 5/16/25 at 10:27 AM, the Wound Nurse (WN) A and Director of Nursing (DON) were both interviewed. WN A was asked if they were the responsible staff for the wound care treatments in the facility and WN A replied they initially were responsible for all stage 3 and 4 wounds, however had most recently been responsible for all wounds with the exception of skin tears and preventative creams. WN A was asked if they were ever pulled to work the units as a floor nurse and WN A stated they were. WN A stated on the days they are pulled to work the floor, the assigned nurses to the resident with wounds are responsible for doing the wound treatment. WN A was asked if they noticed that some floor nurses were not completing the wound treatment whenever they (WN A) were unable to do them and WN A stated they had noticed that lately the nurses have not been doing the wound treatments when they were supposed to. WN A and the DON was then asked about the identified omitted treatments for March, April & May 2025 for R303. WN A stated they noticed the treatments becoming a problem lately and started putting the residents with wound treatments due on the home screen for all nurses to review and on the facility's communication board. The DON explained that the facility had recently terminated nurses they were having care issues with. No further explanation or documentation was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00146970. Based on interview and record review, the facility failed to continuously ensure orders were implemented for supplemental oxygen and for a CPAP (continuous positive airway pressure) machine, failed to implement care plans for chronic hypoxic and hypercapnic respiratory failure, failed to implement interventions for supplemental oxygen and the use of a CPAP machine, failed to provide the correct settings for the non-invasive ventilation as ordered by the Pulmonologist, failed to administer antibiotics as prescribed, and failed to provide the necessary CPAP/BiPAP (bilevel positive airway pressure) ventilation as needed for one R707 of two residents reviewed for falls, resulting in multiple incidents of respiratory distress and a change of condition that resulted in a fall, an acute corner fracture of the C5 vertebral body anteriorly and inferiorly, ultimately resulting in the residents death. Findings include: Review of a complaint submitted to the State Agency documented concerns of the care the facility provided to the resident (R707) who had a fall, fractured their back and ultimately died from their injuries. A review of the medical record revealed R707 was admitted to the facility on [DATE] with an admitting diagnosis of acute and chronic respiratory failure and additional diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. Review of the hospital referral provided to the facility upon R707's admission included the following: A Pulmonary consultation dated [DATE] at 9:42 AM, . Acute on chronic hypoxic and hypercapnic respiratory failure . Acute exacerbation of COPD . At discharge can resume home ICS (inhaled corticosteroids)/[NAME] (long-acting beta agonists)/[NAME] (long-acting muscarinic antagonist) . Would benefit from home NIV (non-invasive ventilation) given severe chronic hypercapnia. Recommend continued to use QHS (every hour of sleep) & naps . Wean fio2 (fraction of inspired oxygen) for goal SPO2 (saturation of peripheral oxygen) 88-92%. Currently on his baseline 3L (liters) nc (nasal cannula) . appears high risk for recurrent exacerbations given severe disease at baseline . continue all aggressive care at this time . A review of the hospital After Visit Summary (dated [DATE]) provided to the facility at R707's admission documented the following: . New Pap Machine & Supplies. Follow up with CPAP facility and pulmonology. Estimated Length of Need: Lifetime . Type of machine: CPAP, Heated Humidifier?: Yes, Type of Mask: Full Face Mask 1 per 3 months. CPAP 5 cm (centimeters), Tidal volume 480, rate 18, inspiratory time 1.2, max (maximum) pressure 37, min (minimal) pressure 7 . SPECIAL DISCHARGE INSTRUCTIONS . Very important to make sure you wear CPAP during sleep and with naps. Maintain nasal cannula throughout the rest of the day . A review of the Nursing admission note dated [DATE] at 6:55 PM, documented in part . Resident arrived to the facility via ambulance . With 02 at 3 L/m (liters/minute), at 91% saturation . Resident has CPA machine brought in by RT (Respiratory Therapist) but verbalized refusal to use it . Review of the medical record revealed no documentation of a physician order for the use of a CPAP as recommended by the hospital and no orders for oxygen administration. A review of a Nursing note dated [DATE] at 7:55 PM, documented in part . RT arrived with resident's CPAP. RT verbalized that she is unable to reach prescribed IPAP calibration of 37 but put it at 30. RT verbalized that 30 is the maximum calibration and that he would need a non invasive ventilator for the prescribed CPAP dosing which would be harder to acquire. Resident however declined to use CPAP and verbalized that he does not want to use it as it is uncomfortable for him and has caused bruising and abrasion on his nose. Review of the medical record revealed no notification to the Physician or interdisciplinary team to inform them of the CPAP machine settings concern and no notification of R707's refusal to wear the CPAP. Further review revealed no documentation of discussions for interventions to help prevent the CPAP nasal discomfort and no documentation of potential alternative methods and/or treatments. There was also no documentation of education provided to the resident regarding the refusal of the CPAP as ordered by the Pulmonologist. A review of the medical record revealed no documented assessment or evaluation completed by the RT that delivered the CPAP machine. Further review of the medical record revealed no implementation of care plans/interventions for R707's CPAP machine or Oxygen administration. Review of a Nursing note dated [DATE] at 5:51 AM, documented R707 had a change of condition Respiratory Arrest and was transferred to the hospital. Review of the hospital records for [DATE] to [DATE] hospitalization revealed the following: An Internal Medicine consult dated [DATE] at 1:33 PM, documented in part . PMHX (primary history) COPD on 3L NC (nasal cannula) at baseline . presented . for hypoxia. Patient was noted to have SpO2 saturations at 60% on 10L NC, patient was then placed on a non-rebreather en route with improvement to SpO2 100%. Patient noted to initially be in respiratory distress upon arrival. Initially in ED (emergency department), patient minimally responsive, not responding to questions or commands . Active Hospital Problems . AMS (altered mental status) secondary to hypercapnia, Acute on Chronic hypoxic respiratory failure with hypercapnia, Severe emphysema/COPD . The resident was admitted to the Intensive Care Unit (ICU). Review of a Pulmonary & Critical Care Specialists consult dated [DATE] at 8:57 AM, documented in part . presented . with a complaint of hypoxia, noted as low as 60s% . has end stage COPD, recently admitted to the ICU for a severe exacerbation, requiring many days of near-total BIPAP dependence . He is conversationally dyspneic and difficult to hear while on BIPAP. He is complaining of being thirsty. Per ED/IM (emergency department/internal medicine) notes he was saturating adequately on NRB (non-rebreather) but still felt dyspneic and asked to be placed on PAP which some improvement after this . ASSESSMENT AND PLAN: Acute on chronic hypoxic and hypercapnic respiratory failure, mostly chronic but very severe COPD . Recommendations: Will need maximal nebulized bronchodilator support (schedule Xopenex+Atrovent (respiratory medications) q4 (every four hours) along with Pulmicort (respiratory medication). Needs to be maintained on triple therapy [NAME]/[NAME]/ICS in outpatient if he can ever be stable enough to be maintained there. Would continue home azithro (azithromycin- antibiotic) MWF (Monday, Wednesday, Friday) along with singular (respiratory medications). Continue NIPPV (noninvasive positive pressure ventilation) (AVAPS- average volume-assured pressure support) qHS (every hour of sleep) and with naps- need to ensure long enough breaks to avoid worsening skin breakdown on nose . Only managed to reside outside of hospital environment for 3 days, he is very dependent on NIPPV . A review of an Internal Medicine consult dated [DATE] at 10:56 AM, documented in part . showing some improvement of his condition. He is more alert. Able to answer questions although does seem weak and fatigued. He has been transitioned to nasal cannula. Continue to wear BiPAP at night as he has high propensity for CO2 (Carbon Dioxide) retention and narcosis . Review of a hospital Pulmonary Teaching Service Progress Note dated [DATE] at 8:08 AM, documented in part . Patient seen and examined . Doing fairly on 3L (3 liters of oxygen) . arrangements made for SAR (Sub Acute Rehab) at 1pm today . Recommendations . Continue home azithro (antibiotic) MWF along with singular, Continue NIPPV (AVAPS) qHS and with naps- need to ensure long enough breaks to avoid worsening skin breakdown on nose - if AVAPS not available at facility and patient still wanting to try BIPAP usage can be put on 20/8 IPAP/EPAP (otherwise if transitioning into Hospice then patient can be given nasal cannula and dyspnea can be treated with morphine primarily rather than PAP . he is very dependent of NIPPV; agree with palliative care following case given recurrence admissions with end stage disease burden, agree with taking some palliative steps such as adding morphine for air hunger. Current plan is that patient would like to try going back to SAR 1 more time, but if failing again then he would like to go to a hospice facility . instead of coming back to hospital . Overall they feel patient is reaching a better/more realistic understanding of his poor prognosis . Review of an Internal Medicine consult dated [DATE] at 9:30 AM, documented in part . awake and resting comfortably in bed on 3 L of oxygen through nasal cannula. He is aware of discharge . Patient with end-stage emphysema and would be hospice appropriate however he is not ready to partake of hospice services . We are moving him to subacute rehabilitation today . He is leaving in improved condition. A review of a Nursing note dated [DATE] at 2:22 PM, documented in part . Nurse received resident in room by 2 ems (emergency medical services) drivers from (hospital initials) . RESIDENT A&OX3 (alert and oriented times three) . Resident is total dependent 2 person assist with all adl care . Resident is a fall risk due to overseeing limits and weakness . Resident lung sounds show expiratory wheezing in bilat (bilateral) anterior and posterior lungs . Resident in room resting eyes closed with no s/s (signs/symptoms) of distress at this time . This note was documented by Registered Nurse (RN) E. Review of the referral packet provided to the facility on [DATE] at 10:30 AM, contained the pulmonologist consult that documented the recommendations of . Continue NIPPV (AVAPS) qHS (hour of sleep) and with naps - need to ensure long enough breaks to avoid worsening skin breakdown on nose . The referral also contained the Internal Medicine consult that documented in part . remains on BiPAP mask . Patient with end-stage emphysema and continues to have oxygenation issues including CO2 retention and hypoxia . Review of the medical record revealed no documentation of the recommended CPAP or BIPAP applied while the resident was resting as documented above. Further review of the medical record revealed no physician orders for a CPAP, BiPAP or oxygen administration via NC ordered for R707. Review of the [DATE] Medication and Treatment Administration Record (MAR/TAR) revealed on [DATE] at 12:56 PM, a nebulizer treatment was provided to R707 for copd/sob (shortness of breath). Further review of the [DATE] MAR/TAR revealed the facility staff failed to administer the resident's antibiotic (Azithromycin 250 mg- milligrams) on [DATE] and [DATE], as prescribed by the physician. Review of the hospital discharge documents provided to the facility on [DATE] documented in part . Azithromycin 250 mg (milligram) . take 1 tablet . 3 times per week Monday, Wednesday Friday for COPD . Last time this was given: 500 mg on [DATE] - 4:28 PM . A review of a Physician note dated [DATE] at 3:00 PM, documented in part . hospitalized at (hospital name) from [DATE] through [DATE] . The patient is status post-hospitalization for hypoxia and respiratory failure. He was noted to by hypoxic on 60% on 10 liters. The patient had a previous hospitalization from [DATE] to [DATE] for chronic obstructive pulmonary disease exacerbation and atrial fibrillation with rapid ventricular response. The patient has recurrent hypercapnia. The patient requires BiPAP and he is noncompliant . He is awake. He is alert. He is oriented x3. Insight and judgment is intact . Continue supplemental oxygen . Continue BiPAP at h.s . Azithromycin every Monday, Wednesday, and Friday . Review of the medical record revealed no ordered supplemental oxygen or an order for the BiPAP and/or CPAP to be provided. Further review of the medical record revealed no documentation of noncompliance with the CPAP or BiPAP for the second inpatient readmission. All documentation of noncompliance was identified for the residents first admission into the facility on [DATE]. The resident was sent out to the hospital on [DATE] and educated by the hospital providers on the need for the CPAP and/or BiPAP when asleep at night and for naps. The facility failed to provide these services and care as directed. A review of a Nursing note dated [DATE] at 5:51 AM, documented in part . 95%NC (oxygen saturation level via nasal cannula). Pt has a severe case of anxiety which causes him to mouth breath more frequently. No other concerns at this time . It is unknown as to the liters of oxygen that was provided to the resident on [DATE], as there was no order implemented for the supplemental oxygen. Review of a Nursing note dated [DATE] at 12:40 PM, documented in part . Writer called to room by therapy. Writer entered room and noted resident appeared short of breath and lethargic O2-89% via nasal cannula. Writer contacted primary physician . ordered to place resident on bipap and monitor for any additional changes. Once bipap was placed resident appeared less lethargic . Further review of the record revealed no documentation of the liters of oxygen that was provided via nasal cannula and no documentation of a bipap to have been delivered to the facility and no documentation of the settings the bipap and/or CPAP was set to. The medical record revealed no order for the BiPAP/CPAP or settings for either machine. A review of a note documented a few hours later noted in part . 4:15 p.m. Summoned to room by Nurse Manager. Resident was observed lying in supine position on the floor non responsive to verbal, tactile and painful stimulus, with his head near the oxygen concentrator. Noted laceration to the right side forehead with small amount of bleeding . B/p (blood pressure) 89/50, O2 sat at 60% . 911 was called . resident was transferred out of the facility to (hospital name) . Review of a facility provided Post Fall Evaluation dated [DATE] at 4:15 PM, documented in part . Fall Description Details . Non-responsive . Lost strength/appeared weak . lying on supine position on the floor with head near the oxygen concentrator . Observed on the floor (unwitnessed) . What was the guest/resident doing during or just prior to fall? On the bed . resident's usual mental status- usually alert + responsive . Were temperature, pulse, respirations and/or O2 Sat out of normal range for this guest/resident? (not answered and left blank) . root cause- non-responsive respiratory distress . sent to the hospital for further evaluation . Review of the hospital medical record revealed the following: An Emergency Medicine consult dated [DATE] at 4:38 PM, documented in part . Chief Complaint Patient presents with - Unresponsive . arrived to ED (emergency department) . Suspected fall, Pt (patient) found on the ground unresponsive to verbal or painful stimuli . Patient on the ground at his nursing facility unresponsive to painful stimuli and saturating at 60%. Patient arrived and was being bagged by EMS in the low 90s . He is in acute distress . Noted hematoma to patient's right parietal region . Pupils equal but unreactive . Patient mechanically ventilated . Capillary refill takes more than 3 seconds . Skin is cyanotic, mottled and pale . He is unresponsive . CT Trauma Protocol Head/Brain w/o IV contrast . Impression . Right frontal soft tissue hematoma . Standard CT of the cervical spin was obtained . Impression: Acute corner fracture of the C5 vertebral body anteriorly and inferiorly Critical findings . Patient was started on fentanyl and propofol drip . Patient to remain intubated until family gets to the bedside. However, patient's family is out of town and will not be back for a couple of hours. At this time patient was admitted to ICU . A Nursing note dated [DATE] at 11:02 PM, documented in part . Decision made by family to extubate pt. See orders. Family at bedside . A Nursing note dated [DATE] at 12:25 AM, documented in part . RN (registered nurse) paged ICU resident (Doctor name) regarding declining heart rate and respirations. (Doctor name) at bedside to assess pt.(patient) TOD (Time of Death) called 0025 (12:25 AM). On [DATE] at 1:25 PM, an interview was conducted with RN E (the nurse that readmitted R707 on [DATE]) with the Director of Nursing (DON) in attendance. When asked if they were aware that R707 was supposed to be on a CPAP/BiPAP machine for naps and sleep at night, RN E replied they were not aware. RN E explained it was their first time being assigned to R707 at the facility. RN E explained they reviewed the discharge paperwork and didn't see anything on there. RN E stated they were not aware that (R707) was on a CPAP until days later when staff was looking for the CPAP machine that was located in the medication room. RN E was asked if they reviewed the referral packet sent from the hospital with the pulmonologist instructions to ensure R707 had the CPAP/BiPAP on when taking naps and at hour of sleep and RN E stated they did not receive or review the referral packet. The DON was then asked the facility's protocol on receiving and the reviewal of the referral packet to ensure the facility is equipped to provide the services and have the equipment that is needed to provide care for the resident once the resident is accepted for admission. The DON explained they have a centralized admission personnel who reviews the packet and they (the DON) also reviews the packet as well to ensure the resident is appropriate and the facility have all the required equipment and supplies. The DON was then asked if they were aware that the RT was unable to provide the settings for the CPAP/BiPAP machine as ordered by the hospital pulmonologist for R707's initial admission to the facility and the DON stated they did not recall being informed. The DON was asked if they were aware of the staff/physician failure to ensure orders were implemented for the necessary supplemental oxygen and CPAP/BiPAP for both inpatient stays for R707, the DON stated they were not aware however would look into that and follow back up. The DON stated they were able to review the readmission discharge orders for the [DATE] readmission and it did not note an order for a CPAP/BiPAP. The referral was pointed out to the DON that was provided to the facility on [DATE], which contained the documentation of R707 to be dependent on the CPAP/BiPAP and to be utilized during naps and sleeping at night. It was also brought to the DON's attention that the supplemental oxygen was not ordered on the readmission discharge orders either, however the facility staff provided it because they knew R707 required it, just as R707 required the use of a CPAP/BiPAP for naps and sleeping at night. The DON was asked why the staff provided supplemental oxygen if it wasn't on the hospital discharge orders and they did not have a current order to provide it and failed to provide the necessary CPAP/BiPAP, the DON acknowledged the concern. The DON was then asked why there was no plan of care/interventions implemented for the primary diagnosis of this resident for acute and chronic respiratory failure and the use of supplemental oxygen and CPAP/BiPAP. The DON stated they would look into it and follow back up. The DON was also asked why the resident had not received their antibiotic as ordered on [DATE] and [DATE], the DON stated they would look into it and follow back up. At 2:33 PM, the DON returned and stated they were unable to find the requested care plans and physician orders for the supplemental oxygen and CPAP/BiPAP machine. The DON acknowledged the omission of the resident's antibiotic on [DATE] and [DATE]. The DON stated they had plans to implement measures and to provide additional education to prevent this from occurring in the future. No further explanation or documentation was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00142528 Based on interview and record review facility failed to implement and revise care plan interventions timely for one (R901) of three residents reviewed for care plan, resulting in development of two stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcers, undeteced weight loss, and admission to hospital for surgical debridement of the wound and PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube placement. Findings include: R901 R901 was admitted to the facility on [DATE] after hospitalization for fall at home. R901's admitting diagnoses included: Contusion of scalp, osteoarthritis, metabolic encephalopathy, and history of achondroplasia. R901 was living at home with their spouse prior to this fall and hospitalization. Based on Minimum Data set Assessment (MDS) dated [DATE], R901 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. R901 had limited range of motion on both upper extremities, and they were totally dependant on staff assistance for eating and needed extensive assistance with their mobility in bed. R901 was transferred to hospital on 1/26/23 for further weight loss and PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube and worsening wounds. A complaint received by the State Agency read in part, (R901- Name omitted) had a fall which is why he was put in a nursing home. (R901) also can 't use his hands, and he needs to be fed. (R901- Name omitted) was taken to the hospital. (Gender Omitted) had three bedsores .(R901- Name omitted) was put on three antibiotics. (R901 Gender Omitted) also had a feeding tube put in . (R901- Name omitted) is now fragile. A review of R901 ER (Emergency Room) records read in part, EMS is unsure why patient was sent for PEG tube, as patient does not have one. Staff at the facility were unable to explain why they are requesting a PEG tube. Patient denies any complaints at this time and any history or complaints of dysphagia. Patient does complain of sacral decubitus ulcers. A review of admission Braden Scale (score to predict pressure sore risk) dated 11/15/23, revealed a score of 12, indicating that R901 was at higher risk for developing pressure ulcer. A review of R901's Electronic Medical Record (EMR) revealed admission nursing assessment dated [DATE]. The nursing assessment revealed R901 had weakness on both upper and lower extremities with limited range of motion. R901 was admitted with a reddened area in sacrum and the description read reddened area near coccyx. The assessment summary had a note that read, .Patient has a reddened area on (gender omitted) near coccyx will put in for wound care to look at the resident .Patient is a one-on-one feed due to limited mobility hands. Review of R901's EMR also revealed a comprehensive Minimum Data Set (MDS) assessment was completed with an Assessment Reference Date (ARD) of 11/18/23. Review of R901's comprehensive care plan revealed a care plan for skin integrity/risk for pressure sore with interventions that included: Weekly skin assessments and Braden assessments per facility protocol. No other preventative measures to maintain skin integrity were in place during this time frame. A review of admission nutrition assessment dated [DATE] revealed that R901 was at risk for alteration in nutrition and hydration and the interventions included: provide diet and supplements as ordered; offer alternates when less than 50% of meal was consumed; and observe and report significant weight changes to the physician. The facility also completed another MDS assessment (Interim Payment Assessment) with an ARRD date of 11/29/23. Further review of EMR revealed multiple progress note reveal concerns with R901's appetite and food acceptance. R90 had tested positive for Covid on 11/22/23. A rehab practioner note dated 11/22/23 at 15:43 revealed that R901 was referred to speech therapy due to modified (mechanical soft) diet. Practioner note dated 11/27/23 had the same recommendation for RD and speech therapy to follow up related to hypoalbuminemia, protein calorie malnutrition, decreased intake and resident receiving modified diet consistency. There was no speech therapy assessment/care plan on R901's clinical record and it was confirmed by the therapy program manager C that R901 did not receive any speech therapy services. A practioner progress dated 11/29/23 at 9:52 read in part, patient has not been eating or drinking well per nurse reports. (Gender Omitted) reports decreased appetite. Unit manager and patient's nurse reported today wounds have been observed on heels, buttocks, and coccyx. Practitioner assessment included poor intake, pressure sores and plan included wound care consult for multiple acquired pressure sores and RD consult. Further review of R901's wound assessment for sacrum dated 11/29/23 revealed a stage 3 pressure ulcer with the following measurements: Area of 5.7 cm2 with x 8.9 cm (length) x 1.7 cm (width) and 0.2 cm (depth). Review of R901's care plan to maintain skin integrity after stage 3 pressure ulcer, right lateral foot vascular ulcer did not have any new interventions to promote healing and prevent any further skin impairments. A care plan intervention to complete weekly skin assessments that was already in place, since 11/11/23 had a revision date of 11/29/23. EMR did not have any evidence of additional resident specific intervention/care plan implementation after R901 had developed a stage 3 pressure ulcer at the facility. A review of dietary care plan after the identification of facility acquired stage 3 pressure ulcer revealed no additional nutritional interventions to address the decreased appetite and food acceptance. R901 had lost 23.6 lbs. in approximately 45 days after admission to the facility. A dietary care plan revision dated 11/29/23 had updated goals to maintain nutrition, hydration, and monitoring labs with no additional resident specific interventions to achieve the established goals. An interview was completed with facility Dietitian B was completed on 2/27/24, at approximately 1:45 PM. Dietician B was queried about RD consult for R901. They reviewed the EMR and confirmed that R901 had an initial assessment on 11/14/23 and a consult on 1/9/24. Dietician B was queried on the communication/notification process between nursing and dietary. Dietician reported they were receiving copies of order if a Resident had an order. They also reported that they had also discussed during the morning clinical meeting if they were able to attend. Dietician was queried on they were getting notified if they no RD at clinical meeting and no further explanation a provided. Dietician was queried on there was no timely RD follow up and implementation of interventions after R901 had weight loss and had developed pressure sores. Dietician reported that based on the record review there were probably no notifications to RD completed and added that had there been a timely notification they would have followed up. An interview with wound care nurse LPN F was completed on 2/27/23 at approximately 9:30 AM. LPN F was queried about R901 and their process. LPN F explained that they had completed an initial assessment after admission, typically within 24-72 hours after the admission nurse assessment. LPN F was queried on their initial assessment and plan for R901. They reviewed EMR and reported that R901 did not have reddened area as noted on admission nursing assessment, so they did not complete a wound assessment after admission. LPN F reported that they completed wound treatments on weekdays and floor nurses were completing on weekends. LPN F was queried who was responsible to update skin/wound care plans. LPN F reported that they were updating the wound care plans if they identified any concerns. LPN F was queried what was updated for R901 after the facility had identified a stage 3 pressure ulcer on 11/29/23. LPN F reviewed the clinical record and reported that turning and repositioning frequently and to moisture barrier cream was after incontinence episodes were initiated. When queried why turning and repositioning was not in place when they were identified as high risk and no further explanation was provided. An initial interview with Director of Nursing (DON) was completed on 2/26/24, at approximately 11:30 AM. DON was queried on the facility's weight protocol. DON was queried about R901's risk on admission and timeliness with the interventions. DON reported that R901 had multiple comorbidities and had interventions in place. DON reported that they were not sure of the timeliness of the interventions, and they would check. No other information was provided prior to exit. A review of the facility provided document titled Care Planning with a revision date of 6/24/21 read in part, every resident end the facility will have a person centered plan of care developed and implemented that is consistent with the residents rights, based on comprehensive assessment that includes measurable objectives and time frames to meet a residence medical nursing and mental and psychosocial needs identified in the comprehensive assessments and prepared by the interdisciplinary team who includes but not limited to attending physician and I just to a nurse who's responsible for the resident a nurse aide a member of food or nutrition services the resident or the representative therapy staff has required and any other ancillary staff. Additional resources will be utilized to ensure that any additional needs or risk areas are identified. Procedure: 1. Residents will be assessed as they are admitted and readmitted to the nursing facility to determine their physical, psychological, emotional, medical, and psychosocial needs. The results of interdisciplinary assessment will be used to develop, review and revise resident's comprehensive care plans. 2. The care plan must be specific, resident centered, individualized and unique to each resident and may include: It should be oriented toward preventing avoidable decline. How to manage risk factors. Address/include resident strengths. Current standards of practice. Treatment objectives should have measurable outcomes. Respect the residence right to refuse treatment. If the resident has refused treatment, does the care plan reflect the facility's effort to find alternative means to address the problem? Place an interdisciplinary approach to include certified nurse aide. Involved the family\ representatives if possible. Involve and communicate the needs of the resident with the direct care staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation Pertain to Intake#: MI00142528 Based on record review and interviews facility failed to timely identify and address the nutritional needs; and monitor weights for one (R901) of three high risk residents reviewed for nutrition and weight loss. This deficient practice resulted in, undetected weight loss, further decline in nutritional status, developed two stage three pressure ulcers during their stay at the facility and transferred to hospital for PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube placement and surgical debridement of the wound. Findings include: R901 was admitted to the facility on [DATE] after hospitalization for fall at home. R901's admitting diagnoses included: Contusion of scalp, osteoarthritis, metabolic encephalopathy, and history of achondroplasia. R901 was living at home with their spouse prior to this fall and hospitalization. Based on Minimum Data set Assessment (MDS) dated [DATE], R901 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. R901 had limited range of motion on both upper extremities, and they needed moderate staff assistance for eating and extensive assistance with their mobility in bed. R901 was transferred to hospital on 1/26/23 for further weight loss and PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube and worsening wounds. A complaint received by the State Agency read in part, (R901- Name omitted) had a fall which is why he was put in a nursing home. (R901-Name ommitted) also can 't use his hands, and he needs to be fed. (R901- Name omitted) was taken to the hospital. (Gender Omitted) had three bedsores .(R901- Name omitted) was put on three antibiotics. (R901 Gender Omitted) also had a feeding tube put in . (R901- Name omitted) is now fragile. A review of R901 ER (Emergency Room) records read in part, EMS is unsure why patient was sent for PEG tube, as patient does not have one. Staff at the facility were unable to explain why they are requesting a PEG tube. Patient denies any complaints at this time and any history or complaints of dysphagia. Patient does complain of sacral decubitus ulcers. Review of R901's hospital admission records and Discharge summary dated [DATE] revealed that that R901 was admitted to the hospital with advanced and infected pressure ulcer to the sacrum/coccyx (tail bone) area that extended to the bone. The infected wound needed surgical removal of unhealthy tissues. R901 had also developed another stage 3 pressure ulcer on the right hip area with exposed fat layer. R901 also had surgery for a PEG tube placement to receive nutrition and hydration due weight loss and protein calorie malnutrition. Further review of hospital records revealed a surgery note that read, depth of the wound: muscle. Size of the wound debrided 10 cm. x 14 cm. with eschar and 4 cm. undermining .3 cm. x 4 cm. wound inferior and right to the sacral wound. The infectious disease specialist note dated 1/27/24 revealed that R901 received three different antibiotics that were administered intravenously. Review of Nutrition consult from hospital dated 1/30/24 read in part, Wife reported pt with significantly decreased PO intake at nursing home . Reported pt only eat a few bites per day. Pt confirms this. States that he was previously eating regular food when he lived at home with his wife, but when he moved to a facility they placed him on pureed diet. He didn't like the food-tastes bad. Additionally he states that he tried supplements but they made him use the bathroom .'. A review of R901's code status from the facility dated 12/27/23 revealed that R901's wishes were to remain full code. A physician admission progress dated 1113/23 at 9:46 read in part, The patient has been deemed competent to make decisions on their behalf. In the course of discussing risk benefits, and alternatives to the advance care directive options were reviewed with patient. This decision included CPR (Cardiopulmonary Resuscitation), PEG tube placement ventilator support. Patient desires to be a full code. A Review of R901's Electronic Medical Record (EMR) from the facility revealed a physician order dated 1/26/24 read, Transfer to hospital related to failure to thrive and worsening wounds and another order that for 1/26/24 that read, New order from MD to send resident to hospital for PEG tube placement and coccyx wound evaluation. Further review of physician orders and discharge summary from the hospital revealed that R901 was admitted with regular diet that was changed to mechanical soft consistency on 11/21/23. A review of R901's progress notes revealed an admission nutrition assessment dated [DATE]. R901's admission weight was 115 lbs. The RD (Registered Dietician) summary and recommendations read in part, .admitted for rehab S/p hospitalization for multiple falls, failure to thrive .PO (eating by mouth) 51% - 100%, which may be suboptimal at times .will provide 2 times/day 18 gm protein. No edema noted, no open areas, coccyx red .nitration goal is for no weight loss, PO to meet >75% of nutrition needs skin to be intact. A review of R901's weight record revealed the following weight entries: 11/13/23 at 14:59 - 115.8 lbs. 12/29/23 at 10:02 - 92.2 lbs. (23.6 lb. weight loss) 1/11/24 at 16:24 - 96.4 lbs. The weight records did not reveal any periodic and consistent weight monitoring for R901 after admission weight. After the initial weight, the 2nd weight was completed approximately 45 days after the admission weight. A physician orders dated 11/17/23 read, Dietary consult, please reevaluate patient for hypoalbuminemia and another order administer 1 liter 0.9 normal saline via hypodermoclysis (administering fluids through skin for hydration) at rate of 60 ml. per hour. Further review of R901's progress note did not reveal any RD consults or follow up after the initial nutrition assessment. An RD progress note dated 1/9/24 at 10:09 read in part, Approached by wound nurse concerning new wound right ischial tuberosity stage 3 (pressure sores that extend past the dermis, the skin's second layer and reached the tissue fat layers beneath), continues with sacrum stage 3 and arterial R heel. Diet of mechanical soft frozen nutrition treat BID (2 times per day) and pro-stat 30 ml. QD (one time /day) .recommend ensure plus BID for additional 750 kcal (kilocalories) 26 gm protein .logged for weight loss recommendations for physician. A nursing progress note dated 11/22/23 revealed that R901 tested positive for COVID, and they were placed on isolation under droplet precautions. A review of the practioner note dated 11/22/23 revealed that R901 reported poor appetite and multiple recommendations that included Dietary to evaluate protein calorie malnutrition, push PO fluids as tolerated. The recommendations were not followed and there were no RD follow ups completed. A rehab practioner note dated 11/22/23 at 15:43 revealed that R901 needed 1:1 feeding assistance and referred to speech therapy due to modified diet. Practioner notes (x 2) dated 11/27/23 had the same recommendation for RD and speech therapy to follow up related to hypoalbuminemia, protein calorie malnutrition, decreased intake and resident receiving modified diet consistency. There was no speech therapy assessment or follow up on R901's clinical record and it was confirmed by the therapy program manager C. A practioner progress dated 11/29/23 at 9:52 read in part, patient has not been eating or drinking well per nurse reports. (Gender Omitted) reports decreased appetite. Unit manager and patient's nurse reported today wounds have been observed on heels, buttocks, and coccyx. Practitioner assessment included poor intake, pressure sores and plan included wound care consult for multiple acquired pressure sores and RD consult. Review of R901's Care plan revealed that R901 the following nutritional interventions implemented on admission due to their diagnoses and risk that included, observe and report to physician significant weight changes 3% in 1 week, 5% in month, 7.5% in 3 months, >10% in 6 months; offer an alternate when less than 50% of the meal is consumed; provide and serve supplements as ordered dated 11/14/23. The care plan also revealed that R901 needed total staff assistance with eating due to their limited range of motion on their upper extremities. A progress note titled e-Interact SBAR Summary for providers, revealed that change in condition were reported due to weight loss and pressure ulcer and R901 was transferred to hospital. An interview with complainant was completed on 2/20/24 at approximately 10:10 AM. During the interview they reported that R901 was at home prior to hospitalization for the fall. R901 was using a walker, and they were assisting at home. They also reported that R901 was not getting the assistance they needed with eating. R901 did not like when the diet was changed. Complainant also reported that R901 did not have any sores prior to the admission to the facility. R901 developed multiple sores during their stay at the facility. The complainant reported that they saw the pictures of the sores and they were deep. The complainant reported that they were able to visit R901 at the facility only on weekends due to their health condition. An initial interview with Director of Nursing (DON) was completed on 2/26/24, at approximately 11:30 AM. DON was queried on the facility's weight protocol. DON reported that they completed weight on admission and then weekly x 4 weeks. The residents were weighed monthly after 4 weeks unless their interdisciplinary team assessment indicated otherwise. A follow-up interview was completed on 2/26/24 at approximately 6:20 PM. DON reported the R901 was had contractures and other comorbidities, tested positive for covid on 11/22/23 and lost appetite. They had RD consult and diet changes. DON was queried about R901's risk on admission and timeliness with the interventions. DON reported that they were not sure of the timeliness, and they would check. No additional information was provided prior to the exit. An interview was completed with facility Dietitian B was completed on 2/27/24, at approximately 1:45 PM. During the interview Dietician B was queried if they had completed the assessment and follow up for R901. They reported that Dietitian who completed the assessment no longer worked for the facility, and they were covering the facility. They also reported that they worked part time and had picked up additional days to assist and there were 2 other RD assisting. Dietician B was queried about RD consult for R901. They reviewed the EMR and confirmed that R901 had an initial assessment on 11/14/23 and a consult on 1/9/24. They had reviewed the R901's weight record and confirmed that there were only 3 entries. Dietician B was queried on the communication/notification process between nursing and dietary. Dietician reported they were receiving copies of order if a Resident had an order. Dietician also reported that the interdisciplainary team had discussed during the morning clinical meeting, if they were able to attend the meeting. Dietician was queried on how they were getting notified if the RD did not attend the clinical meeting; no further explanation a provided. Dietician was queried on why there were no timely RD follow up after R901 had weight loss and had developed pressure sores. Dietician reported that based on the record review there were probably no timely notifications from nursing team to RD and added that if there had timely notifications dietician would have followed up. An interview with Therapy Program Manager C was completed on 2/27/24, at approximately 11:10 AM. During this interview Therapy Manager C reviewed EMR and confirmed that R901 did not receive any speech therapy services. A review of the facility provided document titled Weight Change with a revision date of 9/22/23 that read in part, Residents will be monitored for significant weight changes on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as usual body weight and protein levels; unless the resident clinical condition demonstrates that is not possible. Since ideal body weight charts have not been validated for institutionalized elderly, weight loss (or gain) is a guide for determining nutritional status. Therefore, the evaluation of significant weight gain or loss over a specific period of time is an important part of the evaluation process. Practice guidelines: 1. All residents will have a baseline evaluation of their nutritional status within seven days of admission/readmission. The evaluation will identify risk factors for altered nutritional status. 2. Residents will be weighed upon admission slash readmission; Weekly times 4, then monthly or as indicated by the physician and/or the medical status of the resident and document the results in the medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #2 This deficient practice pertains to intake #MI00139866, and #MI00141946. Complaints were made to the State Agency that alleged the facility failed to appropriately monitor blood glucose levels. Based on interview and record review, the facility failed to document blood glucose readings for one resident (R702) of two residents reviewed for blood glucose monitoring resulting in the potential for unknown deviations from normal blood glucose levels. Findings include: On 1/16/23 at 11:05 AM, a review of R702's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and discharged on 1/29/23. R702's diagnoses included: heart failure, diabetes, high blood pressure, and stage IV chronic kidney disease. A review of R702's physician's orders and medication administration record (MAR) for January 2023 was conducted and revealed they received 63 units of long acting insulin every night at bedtime as well as had an order for blood sugar monitoring every eight hours at 6 AM, 2 PM, and 10 PM. The MAR revealed check marks for the blood glucose monitoring being done every 8 hours on 1/26/23 thru 1/29/23, however; there were no documented values of the blood glucose levels. Continued review of R702's closed clinical record included a review of R702's vital signs that included a section to document blood glucose levels. It was noted there was only one value documented for R702's blood glucose levels. On 1/17/23 at 10:58 AM, an interview was conducted with the Director of Nursing (DON) regarding documentation of blood glucose levels. They said the values should have been documented on the MAR underneath where it was checked off the monitoring had been done. A review of a facility provided policy titled, Diabetic Management revised 9/22/23 was conducted and read, .Orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameter to follow and when to notify the physician .Blood glucose measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician immediately .Documentation .Results of blood testing . This citation pertains to Intake(s): MI00141146 This citation has two deficient practice statements (DPS). DPS #1 Based on interview and record review, the facility failed to assess and treat a surgical wound according to physicians orders for one (R705) of one resident reviewed for non-pressure wounds, resulting in a hospital transfer when R705's foot was observed to be swollen, warm, with surgical hardware embedded into the skin. Findings include: Review of a complaint submitted to the State Survey Agency revealed an allegation that the facility neglected to change the resident's surgical bandages as ordered resulting in the resident's foot becoming swollen and the inserted pin shifting and being displaced .resident had to be sent back to the hospital as a result .bandage .was only changed one time in 11 days . Review of R705's clinical record revealed R705 was admitted into the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses that included: displaced fracture of right foot and cutaneous abscess of right foot. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R705 had intact cognition, received intravenous antibiotics, and did not have any surgical wounds. Review of a Nurses Note dated 11/25/23 revealed the following documentation, At approximately 1030 (10:30 AM) resident (R705) stated she needed to have her dressing changed to her right foot wound. Informed resident that the dressing would be changed today by writer. Old dressing removed at approximately 1300 (1:00 PM) observed swelling from right foot to the right ankle. Sutures intact, along with 3 surgical pins. One of the pins was embedded into the skin. Resident's foot warm, not hot, pink in color, with some areas of dried blood noted. Resident stated her foot did not look like that before that it was not swollen and the pin was sticking out not embedded .Writer called resident's sister/guardian .Stated she had seen residents foot in the hospital and the pin was not embedded but sticking out like the others and the foot had not been swollen (Physician 'L' ) notified of resident's current condition, ordered to transfer resident out to the hospital . Review of R705's After Visit Summary provided to the facility by the hospital revealed the following discharge instructions: Wound/Incision Care .Wound VAC (vacuum assisted wound closure - a type of wound care that uses a suction pump, tubing, and a dressing to remove excess drainage and promote healing of complicated wounds) to be changed twice a week - 125 mmHG (millimeters of mercury - a measurement of pressure) of continuous pressure. Small black foam within dorsal medial (top inside) wound. Incision site wounds to be changed every other day consisting of flushing the wounds with saline, applying with Betadine (antiseptic), 4 x 4 gauze, Kerlix (bandage roll), and reapplying a well padded (with web roll) posterior splint . Review of R705's Physicians Orders revealed the following orders: An order dated 11/14/23 with a start date of 11/17/23 (four days after R705 was admitted into the facility) for Wound Care order: Right dorsal (medial) foot every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for Wound Cleanse with normal (saline), pat dry. Cut black foam to size of wound, apply occlusive dressing (wound dressing that seals out air, fluids, and contaminants) over the black foam to secure in place. Connect tubing. Turn on wound vac (at) 125 mmHG, low continuous suction and ensure seal is secure. Wrap over with kerlix AND as needed for Wound. If unable to maintain suction or vac malfunction: Disconnect vac. Clean area with normal saline, dry, apply saline soaked gauze to area, cover with 4 x 4 gauze and ABD pad, wrap in kerlix. An order dated 11/14/23 with a start date of 11/15/23 for Wound Care Order: Right foot (dorsal lateral - top outer and plantar medial - bottom inside) every day shift for surgical wound. Cleanse area with normal saline, dry, apply adaptic to surgical site, then betadine impregnated gauze to surgical line, cover with 4 x 4 gauze, ABD pad, wrap with kerlix and secure with tape. Apply splint and ACE wrap. The same order was also ordered on an as needed (PRN) basis. Review of R705's Treatment Administrator Record (TAR) for November 2023 revealed the wound vac treatment ordered every Mon, Wed, Fri to the right dorsal medial foot was done one time on 11/17/23 and was not administered on 11/20/23, 11/22/23, and 11/24/23. The daily treatment to the right dorsal lateral and plantar medial foot was not administered on 11/15/23, 11/16/23, 11/18/23, 11/19/23, 11/20/23, 11/21/23, 11/22/23, and 11/24/23. Review of a Nursing Comprehensive Evaluation completed on 11/13/23 upon R705's admission revealed R705 had a right ankle (inner) wound. There was no further description of the wound. Review of R705's progress notes revealed the following: A Skin/Wound Progress Note dated 11/14/23 that documented, Skin assessment completed .The following skin alterations were noted during assessment .Right foot 3 surgical sites noted, see Skin & Wound evaluation for wound details. Dressing change completed by writer (It should be noted that there was no active wound care orders on 11/14/23) . A Nurses Notes progress note dated 11/25/23 that documented, Transfer resident out to hospital for evaluation of right foot surgical wound. There were no progress notes that documented an assessment of R705's surgical wounds to the right foot. Review of R705's Skin & Wound Evaluations revealed incomplete wound assessments started on 11/14/23 that were in progress as of 1/16/24. Review of a Skin & Wound Evaluation for R705's Right Dorsum Foot, dated 11/14/23 revealed R705 had a surgical wound to that area with dehiscence - partial or complete separation of the outer layers of the joining incision. The assessment was incomplete and was not signed. There was no documentation in R705's clinical record that indicated the dehiscence was discussed with and/or evaluated by a medical provider. Review of a second Skin & Wound Evaluation for the right dorsal foot indicated R705 had two sutures. The assessment was incomplete and not signed. Review of a Skin & Wound Evaluation for R705's right medial foot dated 11/14/23 was incomplete, unsigned and documented there were 4 sutures to the area. Further review of R705's full clinical record revealed no additional assessment or evaluation of R705's surgical wounds. Review of a care plan initiated for R705 on 11/13/23 and revised by Wound Care Nurse 'M' on 11/14/23 revealed, (R705) has actual skin impairment to skin integrity r/t (related to) surgical wound to right foot. Interventions initiated on 11/14/23 did not address the wound vac or any specifics related to the surgical wounds. On 1/17/24 at 11:42 AM, the Administrator explained Wound Care Nurse 'M' was unavailable for interview. On 1/17/24 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's skin management program, the DON reported if a resident was admitted with a wound, it was identified by the admitting nurse who conducted the head to toe skin assessment and Wound Care Nurse 'M' came behind to do a full assessment of the wound within a few days. The admitting nurse was responsible for entering the treatment order based on the hospital discharge records. The DON further explained wound assessments were completed on a weekly basis by Wound Care Nurse 'M' and the staff nurses did head to toe skin assessments weekly. When queried about who was responsible to provide wound treatments, the DON explained the staff nurses did treatments unless it was a complicated wound, then Wound Care Nurse 'M' did the treatments. When queried about how it was known if a treatment was done per the orders, the DON reported the nurse signed off on the TAR. When queried about who did wound VAC treatments, the DON reported Wound Care Nurse 'M'. When queried about how the facility ensured treatments were done according to orders, the DON reported she expected Wound Care Nurse 'M' to monitor. When queried about R705, the DON reported she did not recall that resident. When queried about the missed treatments and incomplete and missing wound assessments for R705, the DON reported they were aware the facility had some concerns with wounds and they were working on it. Review of a facility policy titled, Skin Management, last revised 7/14/21, revealed, in part, the following: .Guests/residents admitted with any skin impairment will have appropriate interventions implemented to promote healing, a physician's order for treatment, and wound location, measurements and characteristics documented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00140078, MI00140084, and MI00141881 Based on observation, interview, and record review, the facility to assess newly developed facility acquired pressure ulcers in a timely manner, perform accurate and timely ongoing assessments of wounds and perform treatments per physician's orders for two residents (R#'s R703 and 706) of four residents reviewed for pressure ulcers, resulting in the worsening of a stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcer to a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling) pressure ulcer with exposed bone and suspected osteomyelitis (bone infection). Findings include: R703 Review of R703's clinical record revealed R703 was admitted into the facility on [DATE] and was discharged on 10/22/23 with diagnoses that included: intracerebral hemorrhage and emphysema. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R703 had severely impaired cognition, was totally dependent on staff for bed mobility, transfers, and all activities of daily living, was always incontinent of urine and stool, had significant weight loss and weighed 70 pounds, was at risk of developing pressure ulcers, and had no unhealed pressure ulcers. Review of R703's Total Body Skin Assessments revealed the following: On 8/29/23 it was documented R703 had one new wound. On 9/7/23 it was documented R703 had one new wound. On 9/14/23 it was documented R703 had one new wound. There was no documentation that described the new wounds documented on the skin assessments. Review of R703's progress notes revealed the following: A Nurses Note dated 8/25/23 that read, Resident has an open wound bed to sacrum. Resident has red area to right hip. Resident has red areas to right buttock. Writer cleaned sites with normal saline, applied santyl (a wound dressing used to remove dead tissue from a wound) ointment and border gauze for protection. Wound care notified. Tx (treatment) order placed for resident. There was no description of the wound or diagnosis of the type and stage of the wound. An Encounter progress note written by the physician on 9/4/23 (nine days after the sacral wound was first identified) revealed, .sacral wound .She usually would lay in bed need assistance with all ADL (activities of daily living) care and transfers .Staff reported pt (patient) having new sacral wound unstageable (wound is obscured by devitalized/dead tissue) . There was no documented description of the wound and no measurements. A Total Body Skin Assessment progress note dated 9/7/23 documented, Open wound bed previously reported. The location and description of the wound was not documented. A Nurses Note dated 9/10/23 documented, .Dressing on sacral area done. Writer requested a wound consult for her sacral area . A Nurses Note dated 9/11/23 documented, .Resident has a open wound bed that presents with slough (devitalized tissue) and odor .MD (Medical Doctor) stated that she would place an order for crushed (antifungal medication) to wound bed until wound care MD can assess wound . A Nurses Note dated 9/26/23 documented, Resident has new open wound bed to right elbow .Wound care notified . Review of a Skin & Wound Evaluation for R703 dated 9/19/23 revealed R703 was assessed to have a Stage 4 pressure ulcer to the sacrum that was acquired in the facility. The date the pressure ulcer was identified was not documented. It was documented the pressure ulcer was staged by Wound Care Clinic and measured 3.0 centimeters (cm) in length by 4.0 cm in width by 1.5 cm in depth with 2.5 cm of undermining (destruction of issue extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) and 90 percent slough. It was documented that the primary physician was contacted and the wounds were unavoidable due to resident's decline. However, the wound was first documented on 8/25/23 with no assessment completed until 9/19/23, 25 days after it was first identified per the progress notes. Review of a Skin & Wound Evaluation for R703 dated 9/19/23 revealed R703 was assessed to have a Stage 3 pressure ulcer to the left lateral malleolus (outer ankle) that was acquired in the facility. It was documented the wound had been present since 9/19/23. It was documented the wound was staged by Wound Care Clinic and measured 1.8 cm) by 1.1 cm with 40 percent of the wound filled with slough. Review of physicians orders revealed on 9/15/23, an order to cleanse the left ankle with normal saline and cover with dry dressing was started. However, there was no documentation of when the wound was first identified or what the initial assessment of the wound was when treatment was started on 9/15/23. The first documented assessment of R703's left ankle was when the wound was a stage 3 pressure ulcer. Review of a Skin & Wound Evaluation for R703 dated 10/2/23 revealed R703 was assessed to have a Stage 3 pressure ulcer to the right elbow that was acquired in the facility, six days after it was documented in the progress notes that R703 had an open area to the elbow. There was no date documented to indicate how long the wound was present. It was documented that the wound measured 1.6 cm x 2.5 cm and was 100 percent filled with slough. Further review of the clinical record revealed no prior documentation of an assessment of the open wound to R703's right elbow prior to it being assessed with a stage 3 pressure ulcer on 10/2/23. On 1/17/24 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's process when a resident developed a new pressure ulcer, the DON reported the nurse entered a treatment order and notified Wound Care Nurse 'M'. The DON explained Wound Care Nurse 'M' was expected to assess the wound within 48 to 72 hours. R706 On 1/16/23 at 9:00 AM, a review of R706's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and discharged on 12/27/23. A review of R706's progress notes dated 9/8/23 revealed a re-opening of a stage III (Full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcer. A review of R706's treatment administration records (TAR) for 12/2023 was conducted and revealed missed daily treatments to the ulcer on 12/4/23, 12/7/23, 12/11/23, 12/14/23, 12/16/23, 12/20/23, 12/20/23, 12/22/23, 12/25/23, and 12/26/23. Continued review of R706's clinical record revealed only two wound care consultant forms dated 12/8/23 and 12/22/23, it was noted there was no consult for the week of 12/10/23 thru 12/16/23. It was further noted their was no evidence R706 received any assistance for turning and repositioning or had been transferred to their wheelchair. The consult dated 12/8/23 read, .Wound #1 Sacral is a chronic Stage 3 Pressure Injury Pressure Ulcer .measurements are 3.2 cm (centimeter) length x 1.5 cm width x 1.2 cm depth .No tunneling has been noted .No undermining has been noted. There is a Moderate amount of of serous drainage noted which has no odor . The consult dated 12/22/23 read, .Wound #1 Sacral is a chronic Stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling) Pressure Ulcer .measurements are 2.3 cm length x 1.1 cm width x 3 cm depth .Bone is exposed. Suspected Osteomyelitis (bone infection): Awaiting Results .Undermining has been noted at 12:00 and ends at 4:00 with a maximum distance of 3 cm .The wound is deteriorating . On 1/17/24 at 1:05 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the facility's treatment of pressure ulcers with regards to missing treatments and interventions to prevent the development and worsening of pressure ulcers. The DON indicated they had recognized concerns with pressure ulcers and had been working on it. A review of a facility provided policy titled, Skin Management revised 7/14/21 was reviewed and read, .It is the policy that the facility should identify and implement interventions to prevent the development of clinically unavoidable pressure injuries .Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest resident outcomes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely evaluated and implement effective and accurate treatments for one (R704) of two residents reviewed for pressure ulcers, resulting in R704 not being evaluated by wound care and/or treated for their pressure ulcer for approximately 15 days causing a worsening of the wound on the resident's coccyx and a noted increase in pain. Findings include: A Complaint was filed with the State Agency (SA) that alleged that the facility failed to treat R704's Stage IV pressure ulcer upon admission and for several weeks thereafter. The Complainant further alleged that the facility expressed to them that the ulcer was unavoidable and could not be resolved. Complaint indicated that despite a diagnosis of an unavoidable ulcer the facility failed to initiate any treatment on admission and provide a low air loss mattress to the resident for approximately two weeks. The facility policy titled, Skin Management (12/15/22) was reviewed and documented, in part: Policy: It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes .upon admission .all residents are evaluated for skin integrity .the Braden scale will completed upon admission .Appropriate prevention measures will be implemented and the interventions are documented on the care plan .residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, a physician's order for treatment, and wound location measurements and characteristics documented . A review of R704's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: urinary tract infection, type II diabetes, dementia and protein calorie malnutrition and obesity due to excess calories. A review of the resident's Minimum Data Set (MDS) indicated the resident was severely cognitively impaired and required extensive one to two person assist for most Activities of Daily Living (ADLs). An initial Nursing Comprehensive Evaluation dated 12/14/22 documented, in part: Is this a new admission (Yes) .Bed Mobility: Total assist .K. Skin .Does the resident have any skin conditions? (Yes) .Actual Skin Breakdown Care Plan: Interventions. Apply pressure relieving mattress .Location of skin condition .Coccyx .wound . A Braden score completed on 12/15/22 noted that the resident was at Moderate Risk for pressure sores with a score of 13. An order dated 12/14/22 noted: Wound Care Practioner to eval and treat as indicated . A Skin and Wound Evaluation dated 12/14/22 with a lock date on 12/28/22 (completion date and signed by Wound Nurse A on 12/28/22) documented, in part: .Type .15. Pressure .Unstageable .present on admission .wound measurements .Area 5.4 cm (centimeters) .length 3.1 cm .width .2.5 cm .Goal of Care. 2. Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration .Additional Care .Heel suspension, incontinence management .Mobility .Moisture PAIN SCORE .6 .barrier .Moisture .control .Nutritional .supplementation .turning repositioning.Progress . stable . *It should be noted that there were no documents that noted the size, width, description of the wound upon entry to the building (12/14/22) until noted in the evaluation dated 12/28/22. Further there was no initial order as to a mattress either air loss or with pump noted in the evaluation. A Skin and Wound Evaluation (12/29/22) documented in part: .Type .Pressure .Stage: Unstageable .Location .Coccyx .present on admission .Area 8.9 cm .Length 4.2 cm .Width .3.3 cm .PAIN SCORE -9 .Goal of Care: Slow to heal; wound healing is slow or stalled but stable .Mattress with Pump added to Addition care. R704's Care Plan documented, in part: R704 is at risk for impaired skin integrity/pressure .Decreased mobility .(12/14/22): .interventions .conduct weekly head to toe skin assessments (12/14/22) follow policies/protocols for the preventions/treatment of impaired skin (12/14/22) .Observe dressing frequently (12/30/22) .pressure reduction cushion to w/c (12/30/22) .pressure reduction mattress to bed (low air loss) (12/30/22) .transfer/reposition every two hours(12/14/22) .Wedge .to aide in repositioning (12/14/22) . Attempts to obtain orders pertaining to the treatment of R704 wound to the coccyx were made while reviewing the clinical record. The first order found in the resident's record was as follows: Santyl Ointment 250 Unit .Apply to sacrum topically every day shift for Wound Care Sacrum .Cleanse with NS pat dry, lightly pack with Maxorb AG Santyl oint cover with 4x4 gauze securing with foam dressing . (12/29/22). A review of the residents Medication Administration (MAR)/Treatment Administration Record (TAR) documented the first treatment to the resident's wound was on 12/20/22. Physician Wound Care Note (1/3/2023) authored by Wound Nurse Practitioner (WNP) B documented, in part: .the patient was seen today as a consultation for evaluation of the patient's wounds .this information was obtained from the resident's chart .Pressure ulcer to sacral region, unspecified stage .Wound #1 sacroccyx/bilateral buttocks is a kenndy <sic> Terminal Ulcer (generally starts as a small bruise that is reddish or brown that quickly grows in a short period of hours ) encounter measurements are 10.4 cm length x 5.7 cm width x 2cm depth with an area of 59.28 sq cm and a volume of 118.56 cubic cm. There is a moderate amount of drainage noted with a strong odor .Treatment Orders .Calmoseptine QD (daily) and PRN (as needed) to the peri wound base .Crushed Flagyl (eliminates odors) and Hydrogel daily and PRN for 7 days .cleanse wound with Dakin's ¼ strength additional orders . ROHO mattress . Physician Wound Care Note (1/10/23) authored by WNP B documented, .buttocks is a Kennedy terminal ulcer . measurements are 11.1cm length x 7.7 cm width x 2cm depth with an area of 85.4 sq cm and a volume of 170.95 cubic cm . An additional treatment of Triad Past QD and PRN was added to the treatment plan. On 3/14/23 at approximately 2:30 PM, an interview was conducted with Wound Nurse A. Nurse A reported that they have been working as the facility wound nurse since July 2022. When asked as to the facility protocol for residents who enter the facility with wounds, Nurse A reported that the admitting nurse is to do an initial assessment and ensure that the resident is seen by wound care including the wound physician. Nurse A indicated that the wound physician team is in the buildings on Tuesday. When asked about R704, Nurse A reported that they were out on leave when the resident was admitted on [DATE] and did not return to the facility until 12/28/22. When asked if they were not in the facility who was in charge of ensuring wound care assessments, treatments, etc. were conducted, Nurse A stated that nursing staff, including the Director of Nursing (DON), are able to assess residents and contact the wound care physician/wound nurse practitioner. When asked when the first time the wound physician was notified, Nurse A reported that the facility did not report any concerns to the wound physician and stated that they reported the concern upon their return (12/28/22). When asked if a failure to treat the resident's wound could cause the increase in size and possible increase in pain, Nurse A reported that it could. On 3/14/23 at approximately 2:45 PM, an interview was conducted with the DON. When asked why R704 did not begin treatment for their wound until Nurse A returned to the facility on or about 12/28/23, the DON reported that the facility should have initiated the order for a wound care consult to ensure treatments were in place. When asked as to why the resident did not receive a pressure reducing mattress/low-air-loss mattress until 12/30/22 as noted in the resident's care plan, the DON reported that the facility generally uses non-powered, air-filled mattresses. On 3/14/23 at approximately 3:51 PM, a phone interview was conducted with WNP B. When queried as to R704, WNP B noted that the first time they saw R704 was on 1/3/23. They noted at that time the resident's wound had a strong odor indicating infection and based on their observation noted the wound to be a [NAME] Ulcer. When asked if they were aware R704 was admitted to the facility with what was noted as a pressure sore to the coccyx noted as unstageable with significant smaller depth and width, WNP B reported that it is up to the facility to indicate a resident is to be evaluated as to their wounds. WNP B was asked if the facility should have contacted them per the 12/14/22 order for a wound consult to ensure treatment/interventions for the resident were implemented timely, WPN B noted that they should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consistently identify the root cause of a fall, review, modify and implement effective interventions to prevent further falls for one (R704) of three residents reviewed for falls, resulting in a transfer to the hospital and required multiple staples to repair a laceration to the scalp. Findings include: Review of the medical record revealed R704 was admitted to the facility on [DATE], with diagnoses that included: Parkinson's disease, bipolar disorder and anxiety disorder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of the preadmission hospital paperwork provided to the facility documented in part, . presenting to the ED (Emergency Department) after an unwitnessed fall today and yesterday. Patient is a poor historian . pt.(patient) is not at his baseline for mentation .seems more confused . Review of a Nursing note dated 11/30/22 at 7:41 PM, documented in part . Patient told family member that (R704) has been falling on the floor since they arrived to the facility and getting up by .self. Writer not made aware of the falls until family came and mentioned it. Patient is confused . Review of a facility Incident and Accident Report dated 11/30/22, documented in part . Patient told family member (R704) has been falling on the floor and getting up w/o (without) assistance and w/o telling somebody . Encourage resident to report falls and not get up without examination . INTERVENTIONS IMPLEMENTED . educated Pt (patient) to call for assistance and to wait for assistance. Also educated pt. that if .does fall to let a nurse or staff member know . The Intervention implemented is not effective for a confused resident. Further review of the medical record revealed multiple notes that documented the resident had some confusion. Review of a care plan titled . is at risk for fall related injury and falls R/T (related to): history of falls, Parkinson's, unaware of safety needs, impulsive Initiated 11/26/22, documented no new interventions or modification of interventions after the unwitnessed falls were reported. Review of the medical record revealed no documentation of the Interdisciplinary team to have identified the root cause of the resident falls or reviewed the interventions in R704's care plan to ensure effective and individualized interventions were implemented to prevent further falls. Review of a Nursing note dated 12/2/22 at 1:15 PM, documented in part . At approximately 1:15 PM writer was passing medications to resident and observed (R704) self ambulating with the wheelchair as a walker. Writer attempted to redirect resident to sit down as (R704) was looked <sic> unstable and was shaking, resident fell backwards and hit .head. Writer observed laceration to the back of .scalp, attempted to provide wound care . recommendation to be sent to ER (Emergency Room) for further evaluation and possible stitches . Resident continued to attempt to stand and self-ambulate despite encouragement by staff to stay stationary until EMS (Emergency Medical Services) arrived . Review of an Incident and Accident Report dated 12/2/22, documented in part . Resident was walking with .wheelchair as a walker and fell on the floor. Patient hit .head . Physician requested that we send the patient to the ER (Emergency Room) . INTERVENTIONS IMPLEMENTED . Educated the patient to use the walker to assist when walking. Also, educated to use the call button for assistance and to wait for assistance to come for assistance . Review of a hospital After Visit Summary dated 12/2/22, documented in part . Laceration Repair With Staples . Follow up with (Hospital name) Emergency Department in 5 days . For staple removal . Diagnoses . Fall . Laceration of scalp . Review of a physician order dated 12/3/22, documented in part Monitor scalp laceration for s/s (signs/symptoms) of Infection, notify physician of any changes . Further review of the medical record revealed the staff failed to document the number of sutures R704 received to repair the laceration to their scalp. On 1/3/23 at 1:17 PM, an interview was conducted with R704's Family Member (FA) A who stated the following, . We received a call on 12/2 saying that (R704) was at [hospital name] because (R704) had fallen and I was upset . I was there a few days before and told them about previous undocumented falls at the facility . I asked for the Incident reports from the falls . She (DON) told me I couldn't have a copy of it. I told her that I don't understand because we are just trying to understand how (R704) fell so that we can prevent it from happening again . I got two different accounts on how (R704) fell on 12/2 . (R704) had 8 staples in their head . Review of a facility policy titled Fall Management last approved on 8/18/22, documented in part . The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls . Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls . If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify and assess behavioral changes (that included increased agitation, frustration, a decline in mental and psychosocial well-being), staff failed to follow care plan interventions and notify the physician of changes in the resident condition for one (R704) of one resident reviewed for a death, resulting in the failure of the facility staff to not have provided timely interventions and adequate supervision to R704 who was able to coordinate and carry out their suicide attempt in the facility. Findings include: Review of an Investigation Summary submitted by the facility to the State Agency (SA) documented in part, . the administrator conducted a complete and thorough investigation. The findings of the facility, the resident had a purposeful/deliberated agenda to cause/inflict self-injury. The staff had no knowledge or precursor that resident wanted to bring harm to himself. The resident's demeanor remained unchanged, (R704) was upbeat and there were no changes to their cognition or activities of daily living . The facility followed its abuse policy and self-reported this unforeseen event . Review of the medical record revealed R704 was admitted to the facility on [DATE], with diagnoses that included: Parkinson's disease, bipolar disorder and anxiety disorder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of the preadmission hospital paperwork provided to the facility documented the resident presented to the Emergency Department after a fall at home. Further review of the hospital paperwork revealed an Assessment PT (Physical Therapy) Forms that documented in part, . Pt (patient) presents well below baseline, unsafe for home dc (discharge), anticipate structured rehab at dc . The resident was admitted to the facility for rehab and expected to be discharged back home. Review of a Nursing note dated 12/7/22 at 5:31 PM, documented in part . At approximately 415pm writer observed resident self-propelling back and forth in the hallway in their wheelchair. Writer asked resident if there was anything they needed or anything that I could do for (R704) and (R704) said no. (R704) proceeded back into their room. About 15 minutes later writer was walking past residents room and saw resident on their knees in front of their closet. Writer went in to assess and observed resident with wireless phone cord wrapped around their neck and (R704) was hanging from closet bar. Writer called for help. Cut cord wrapped around residents neck and assisted to the floor. With assistance of other nurses, CPR initiated and 911 called . On 1/3/23 at 12:29 PM, a telephone interview was conducted with Family Member (FA) A (Family to R704) when asked if they had any concerns regarding the death of R704, FA A stated in part, . We have a lot of concerns involving (R704) death . My dad left at 2 PM (left the facility from visiting R704) . I got a call at 4:15 PM . (R704 name) is unresponsive and .is being transported to the hospital . We asked for the video and medical records from 2 PM to 4:15 PM . the police officer had been talking to us and they said in the report that he (R704) was agitated and wanted to go home and (the Director of Nursing- DON- name) denies it. It was all of this conflicting reports . On 1/3/23 at 2:27 PM, a message was left for the detective assigned to R704's death, however a return phone call was not received by the end of survey. On 1/3/23 at 3:23 PM, the administrator was asked to provide the facility's video footage for the date of 12/7/22 from 2 PM until the time of the incident. On 1/4/23 at 8:35 AM, the Administrator prepared video footage for the date of 12/7/21 from 2:23 PM until EMS left the facility to transfer R704 to the hospital. An observation and review of the video footage was completed and revealed the following in part: At 2:23 PM, R704 is observed in the hallway with a grey shirt on and blue pants. The resident was observed propelling and wheeling themselves in the hallway. Shortly after the resident is seen putting an object on the housekeepers cart. A staff member walks by and picked up the object from the cart and puts it back down and continued to walk down the hallway. At 2:35 PM, the housekeeping staff (later identified as housekeeping staff B) was observed to have picked up the object from their cart and gave it back to R704. From 2:37 PM until 2:49 PM, R704 is observed talking to a staff member in the hallway, going to the ice cooler in the hallway and entering and exiting their room multiple times. At 3:01 PM, a staff member enters the resident room (later identified as Physical Therapist- PT D) and exits the room with the resident. The resident appears agitated as they are observed circling in their wheelchair around this staff member in the hallway. The staff and R704 re-enters back into R704's room. At 3:02 PM, R704 is observed leaving their room with the staff member behind them. The staff member is seen talking to the resident in the hallway. R704 begins to follow the staff member to another hallway at 3:03 PM. At 3:07 PM, R704 is again observed on the hallway camera with the PT D holding the back of R704's shirt with the resident ambulating while pushing their wheelchair and entered back into R704's room. At 3:09 PM, a Certified Nursing Assistant (CNA) is observed to have enter the room and at 3:10 exited R704's room. At 3:12 PM, PT D exits R704's room. At 3:25 PM, a staff member enters in to R704's room and then exits a minute later. At 3:26 PM to 3:33 PM, the resident is again observed in their wheelchair in the hallway, talking to a staff member, going to the ice cart and standing up at the ice cart in the hallway, a staff member observes R704 standing up and briefly holds the back of R704's wheelchair up to the resident and at 3:33 PM, the resident enters into their room. A minute later at 3:34 PM, the resident wheels themselves back into the hallway and talks to a staff member. The resident re-enters their room at 3:36 PM. The resident is observed on the hallway camera a few seconds later at 3:36 PM, wheeling themselves to the middle of the hallway then re-enters into their room at 3:37 PM. At 3:41 PM, R704 is observed in their wheelchair in the hallway, two staff members are seen by the resident it appears the staff are talking to the resident. R704 is then observed propelling themselves up the hallway. At 3:45 PM, a staff member stops and talks to R704. R704 begins to propel themselves backwards in their wheelchair up the hallway and is no longer visible on the camera. At 3:46 PM, R704 is again observed on the hallway camera propelling themselves backward in their wheelchair to their room. Two minutes later at 3:48 PM, the resident exits their room and again re-enters into their room. At 3:57 PM, R704 is observed exiting their room into the hallway, with what appears to be a white towel on their lap. The resident is seen to have talked to two staff members in the hall and appears to grab another towel and propels themselves up the hallway out of the camera's view. At 4:00 PM, R704 is observed propelling themselves backwards in their wheelchair up the hall then turns the wheelchair around the correct way and uses the hallway wall bar to help wheel themselves in the hall. R704 is observed to have dropped a towel in the hallway. At 4:01 PM, a staff member picks up the towel and provides R704 with a new towel. R704 is observed in front of their room door, shaking a towel, drops a towel and covers their head with another towel. At 4:03 PM, R704 is seen propelling themselves in the hallway with a towel over their head. At 4:04 PM, a staff member stops and talks to the resident and leaves. At 4:05 PM, the resident enters their room with the staff member and the staff member exits out of the room at 4:06 PM. The staff member is then seen picking up the dropped towel from the floor. At 4:10 PM, a staff (later identified as Certified Nursing Assistant- CNA E) enters into the room and exits the room at 4:11 PM. At 4:38 PM, the nurse enters into the room and runs out of the room. The nurse re-enters the room at 4:38 PM, with another staff member and runs out again at 4:39 PM, the nurse is then observed grabbing the phone in the hallway and goes to the medication cart, bangs on the cart with their hand while reviewing the computer screen at the medication cart. The nurse is then observed running down the hall way and grabs the crash cart while running back to R704's room. From 4:39 PM from 5:18 PM, multiple staff members are observed running to R704's room, the Emergency Medical Services (EMS) arrives and at 5:18 PM, EMS is seen transporting R704 via stretcher in the hallway and out the exit door. On 1/4/23 at 12:16 PM, HS B was interviewed and asked about the interaction with R704 on 12/7/22, when R704 was observed to have put an object on HS B housekeeping cart and HS B picked up the object and handed it back to R704 as observed from the facility's video footage and HS B stated in part they were about to clean R704's room and R704 told HS B to throw the picture away. HS B stated (R704) said I don't want it (R704) used the F word . (R704) said F*** the picture . When asked what was identified on the picture, HS B stated it was a family picture with like four people in the picture . When asked if they told anyone about R704's attempting to throw away their family picture and stating F*** that picture, HS B replied no. HS B was asked if they thought it was a red flag that R704 was trying to throw away or give away their family picture and HS B stated it didn't register at the time, but the next day when they heard what happened with R704 it registered. HS B stated they did not inform anyone of the conversation with R704 until the next day when he heard what happened with the resident. When asked how R704 appeared to be that day, HS B stated usually he would see R704 in their room but this was the first day that they seen R704 was out of their room and in the hallways. HS B stated It was different. On 1/4/23 at 12:37 PM, Occupational Therapy Assistant (OTA) C was identified as one of the staff members that interacted with R704 in the hallway on 12/7/22. OTA C was interviewed and asked about their interactions with R704 on 12/7/22 and OTA C stated that day the resident was pretty agitated and said (R704) had business to deal with and (R704) couldn't deal with us right now. OTA C stated they asked the resident if they wanted to go to the therapy room and they said No, I have business to deal with. OTA C stated they asked the resident if they wanted to talk and R704 replied No. OTA C then stated . (R704) was in the hallway rolling their wheelchair. (R704) was agitated about something and wouldn't tell me about it. I had not seen them like that before . OTA C stated they attempted to work with R704 twice that day but the resident refused. When asked if they told R704's nurse or anyone about the increased agitation and refusal to complete their OT exercises, OTA C stated they did not tell anyone. OTA C stated I did talk to the Certified Nursing Assistant (CNA) and asked what happened in R704's room because the nursing assistant was in the room cleaning up something and the CNA stated they didn't know but was cleaning it up. OTA C then stated they did inform their supervisor at the end of the day that they were unable to get my therapy minutes in with the resident. When asked why they didn't inform R704's nurse of the residents increased agitation, OTA C replied . (R704) was down at the nurses station and they (nurses) were standing out there, so I thought they saw (R704) and knew what the agitation was about. The nurses were just talking to (R704). (R704) was quite noticeable and very agitated . OTA C stated R704 liked a particular exercise machine in the therapy room so they tried to encourage the resident to come to the therapy room and see if it would relax (R704) and talk to them but (R704) said no, (R704) said they had business. OTA C stated this was the first time that R704 refused to do therapy with them, . (R704) kept talking about business that (R704) had to do . On 1/4/23 at 1:27 PM, PT D (the staff member observed on the facility's video footage holding the back of R704's shirt with the resident observed ambulating while pushing their wheelchair) was interviewed via telephone and asked about their interactions and therapy session completed with R704 on 12/7/22 and PT D stated they had worked with R706 the day before (12/6/22) and a little on (12/7/22) but R704 stopped at the gym door on 12/7/22 and said I don't want to go in there I have some business to take care of . I asked if (R704) was sure and they said yes. PT D stated R704 then jumped out of the wheelchair and ambulated while using the wheelchair which is unsafe so they held the back of the residents shirt while they walked. PT D stated the resident did not give them time to utilize a gait belt nor would R704 get back into their wheelchair. PT D stated they did see R704 a little later in the hallway but they couldn't understand what the resident was trying to say to them. PT D stated in part, . it seems like the effects of Parkinson's (R704) was having a hard time with speech and seemed frustrated . When asked if they informed R704's nurse or any administration staff of R704 frustration and refusal to complete their PT session, PT D stated in part . I tried to look for the nurse to tell her that I tried to attempt to see them and t(R704) seemed frustrated and I couldn't see them for therapy . but PT D stated they could not find R704's nurse that day. PT D stated they did talk to OTA C and told the therapist that they attempted to see them but (R704) didn't want to be seen and said they had to take care of business and OTA C stated they were trying to see R704 as well. PT D then stated . (R704)'s mood and behavior was much different that day, (R704) seemed was trying the best they could the day before doing all of the exercises that they could do and they walked back with a roll walker from the gym. It was like day and night as far as behavior . PT D then stated, . (R704) was trying to communicate, but I couldn't understand them and they seemed frustrated. I was confused because I thought it could be a side effect from Parkinson's because (R704) was real shaky . On 1/4/23 at 2:44 PM, Certified Nursing Assistant (CNA) E (Identified as the aide assigned to R704 on the evening of 12/7/22 and also the aide observed on the video footage going in and out of R704's room) was interviewed via telephone. When asked about their interactions and R704's mood on the day of 12/7/22, CNA E stated their shift started at three that day and they felt R704 was frustrated because they wanted to do therapy. CNA E stated prior to going to therapy R704 knocked over their food and water on their bedroom floor so they had to clean it up. CNA E stated when R704 came back from therapy they asked R704 what was wrong and R704 stated . I want to go home. CNA E stated R704 headed to the facility's exit door and they were able to talk to them and the nurse grabbed the back of the wheelchair and redirected (R704). CNA E stated . (R704) was between all of us and (R704) said I want to go home . I told (R704) let's at least eat dinner (this is one of the observations that was reviewed on the video footage when three staff members are seen around the resident, however the ice cart blocked a part of this observation on the facility's video footage). When asked if it was alarming that the resident was trying to leave, CNA E replied Yea, it was but (R704) was known for trying to leave before . I don't know what led to the agitation from dayshift, I don't know. I see them have a few episodes before were (R704) was agitated or just kind of shut down so it wasn't different for me . CNA E was asked if they were sure that R704 had other incidents of trying to leave the facility, agitation or withdrawal because there was no prior episodes documented in the record and CNA E stated that they had witnessed prior incidents. When asked about their interaction with R704 when they entered the resident's room at 4:10 PM on 12/27/22 (as seen on the video footage), CNA E stated . (R704) had threw water and food on the floor so I knew (R704) was agitated so I wanted to peek and see what (R704) was doing. CNA E stated the resident was observed in their wheelchair by the end of the bed watching tv. On 1/4/23 at 3:23 PM, Director of Social Services (DOSS) G was interviewed and asked if they talked to, assessed or had any interactions with R704 on 12/7/22 and DOSS G replied they did not. DOSS G stated they peeked in the resident's room after lunch and the resident was taking a nap so they didn't disturb them. When asked if they were informed of R704's increased agitation and abnormal mood and behavior on 12/7/22, DOSS G denied being informed. When asked if they were informed of R704 to have requested to go home, DOSS G stated they were. When asked who informed them of R704's request to go home, DOSS G could not recall. When asked if they talked to the resident to see if they wanted to be discharge DOSS G stated they did not talk to the resident but they did talk to R704's sister. When asked why they talked to R704's sister regarding the resident request to go home especially if R704 is their own responsible party and DOSS G stated they usually will talk to the family and also the resident, however the resident was sleeping when they peeked into their room. When asked if they were informed of R704 request for the second time in the evening to go home, DOSS G denied they were informed of R704's request. Review of the medical record revealed no documentation of R704 to have consented for DOSS G to have discuss with their sister their request to leave the facility and be discharged home. Review of a behavioral consult dated 12/7/22, documented in part . Complaint: Initial evaluation for psychiatric symptoms and medications . Pt (patient) says (R704) is tired today but mood is OK but a little anxious 7/10 currently. (R704) feels the medications help with mood and that the clonazepam helps with anxiety . Review of the CONTROLLED SUBSTANCES PROOF OF USE for R704's clonazepam 0.5 mg (milligram) tablet, give 1 tablet by mouth every 8 hours around the clock (anxiety medication which was scheduled for 9 AM, 1 PM & 9 PM) revealed on 12/7/22, the residents 9 AM dose was given at 11:37 AM (Two hours and thirty-seven minutes late) and their 1 PM dose was administered at 1:24 PM, not even two hours from the last dose. A medication that was needed around the clock to manage R704's anxiety was administered late on 12/7/22 and the behavioral consult that was conducted on the morning of 12/7/22 had already documented the resident's anxiety at 7 out of 10. It was verified by the facility's Director of Social Services (DOSS) G that the resident was seen by the behavioral group the morning of 12/7/22. On 1/4/23 at 3:49 PM, Licensed Practical Nurse (LPN) F (the nurse assigned to R704 on the evening of 12/7/22) was interviewed. When asked how R704 was the day of 12/7/22, LPN F stated in part . (R704) was antsy. I went on break and came back and (R704) was red and hot. I took their temperature but it was normal. (R704) kept going in the ice bucket and getting ice. The LPN F stated R704 was antsy even before they went on their break which they estimated was around 2:30 PM. When asked about R704 to have stated they wanted to go home, LPN F stated R704 was going up and down the hall and they redirected them a couple of times that day. When asked why R704 couldn't leave the facility if they wanted, LPN F stated they weren't sure. LPN F was asked if they notified the Social Worker, DON or Physician to inform them that the resident wanted to leave, LPN F stated No. LPN F stated . when (R704) was in the hallway they stated they wanted to go home. When asked if anyone asked R704 why they wanted to leave, LPN F stated they didn't remember why. LPN F stated R704 was not their own responsible party and would not be able to leave without family's approval. When asked why R704's anxiety medication was administered late the day of 12/7/22, LPN F explained it was a busy day with two discharges and wound care that had to be done before they finished administering the medications. When asked if they identified a change in R704's behavior on 12/7/22, LPN F stated . (R704) was off that day. (R704) was definitely off that day. Yes, I noticed changes in their behavior . At that time the typed Interview Statement which was submitted to the SA by the facility was read to LPN F, which documented in part, . [LPN F] . The administrator interviewed the charge nurse (LPN F) regarding this event . The administrator asked the charge nurse had she noticed any changes in the resident's behavior. She replied no . LPN F was asked if their statement was accurate and LPN F stated the typed statement was not accurate and LPN F stated again they had noticed changes in R704's behavior and stated . I'm pretty sure that I told the Administration that (R704) was off that day . When asked if they had informed the physician of R704's behavioral changes, LPN F stated they had not. LPN F was then asked to recall the time they found R704 unresponsive and LPN F stated in part, . I was walking by and I saw the lower part of the body. I entered the room I turned the first thing I saw was (R704) in their phone charger . (R704) was hanging from the front . and it was attached to the bar from both sides . LPN F stated with the help of other staff they lowered R704 to the floor and began CPR. Review of a care plan titled MOOD . has the potential for fluctuations in mood R/T (related to) . BiPolar DO (disorder), Adjustment D/O with mixed Anxiety and Depression Initiated 12/5/22, documented the following interventions . Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician . Encourage resident to express feelings and provide time to talk as needed . If resident . experiences mood fluctuations or increased anxiety; attempt to rule out potential causes . Observe and report to SW and/or physician prn acute changes in mood or behavior; feelings of sadness; increased anxiety/agitation, depression, withdrawal/loss of pleasure and interest in activities . diminished ability to concentrate . how resident interacts with others . Multiple facility staff failed to implement the interventions documented on the resident's care plan. Review of the medical record revealed a prescription dated 12/7/22, documented in part . Xanax 0.5 mg QHS (every hour of sleep) PRN (as needed) for anxiety . Further review of the medical record revealed the staff did not implement the order and there was no documentation that noted why the Xanax was prescribed. On 1/5/23 at 10:45 AM, the Director of Nursing (DON) was interviewed and was asked if they were informed that R704 refused OT and PT on 12/7/22, which was abnormal for R704 according to staff who stated all R704 wanted to do was therapy to get stronger and go home. The DON stated they were not informed. The DON was then asked if they were informed of the identified mood and behavioral changes with R704 on 12/7/22 and the DON stated they were not informed. When asked if they were informed that R704 requested to go home the DON stated a staff member did tell them, when asked what staff the DON could not recall. The DON stated they remember after being informed going to the resident's room and talking to the resident. The DON stated when they went to the resident's room R704's father was in the room and it was discussed that they wanted the resident to have a safe discharge and wanted to work on the goal of safely getting in and out of tub (which the resident had at home), the DON stated the resident was in agreement with staying at the facility to continue therapy and get stronger. When asked if they were informed later in the evening of the resident requesting to go home again, the DON stated they were not informed. When asked about the R704's anxiety medications to have been administered late when his anxiety level was already documented at a 7 out of 10 per the behavioral consult that was conducted on the morning of 12/7/22, the DON stated they were not aware that the medication had been administered late. When asked about the prescription found in the resident's chart for Xanax the DON explained when they talked to R704's sister the day of 12/7/22, and the sister stated if R704 doesn't get enough sleep they have changes in their behavior. The DON asked the sister what the resident took at home to help them sleep and the sister stated Xanax. The DON stated they talked to the doctor to obtain the order for the PRN Xanax. It was identified R704 requested to go home sometime before 2 PM (which is the estimated time R704's father left the facility from visiting R704) and again on evening shift when CNA E was on duty. R704 stated twice on the day of 12/7/22 that they wanted to go home. On 1/4/23 at 5:15 PM, the Administrator was interviewed and asked about the differences identified with the investigation summary submitted to the SA by the facility when compared to the staff actual interviews with multiple staff to have identified changes in R704's mood and behavior on 12/7/22 prior to the resident suicide attempt and the Administrator stated they had no idea why the staff would say one thing to them and another to the surveyor. The Administrator was then asked about the multiple staff to have identified the changes in R704's behavior and mood on 12/7/22, with the addition of the resident to have attempted to throw or give away a family portrait, decline OT and PT services which the resident had never done in the past (according to the facility staff) and the failure of staff to follow the interventions documented on the plan of care and notify the physician for additional interventions to be implemented as well as increased monitoring of the resident and the Administrator did not reply but acknowledged the concern. On 1/5/23 at 12:54 PM, Physician H was interviewed and asked if they were notified by the facility staff regarding the behavioral and mood changes of R704 on the day of 12/7/22 and Physician H replied they were not informed. Physician H was then asked if staff informed them on 12/7/22 that R704 requested to leave the facility and Physician H stated they could not recall having been informed. On 1/5/23 at 1:04 PM, the Administrator was re-interviewed and asked if they were notified by any of the facility staff regarding the mood and behavioral changes with R704 on 12/7/22 and the Administrator stated no. When asked if they were informed that R704 requested to leave the facility and go home twice that day, the Administrator stated they were not informed. The Administrator stated they believe their staff are remembering things in hindsight now looking back at the situation, which the Administrator believed was the reasoning for the differences noted in the investigation submitted to the SA when compared to the staff interviews with the surveyor. The Administrator stated the facility will be completing suicide education with their staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake #MI00126220 Based on observation, interview and record review the facility failed to ensure fall prevention safety for one resident (R69) of four residents reviewed for accidents/falls, resulting in R69 falling forward out of their wheelchair and sustaining severe bruising and a laceration to the forehead that required nine sutures. Findings Include: A complaint was filed with the State Agency (SA) that alleged an incident occurred where Certified Nursing Assistance (CNA) Q flipped a resident who fell and sustained injury to their eye and head. The facility Fall Management Policy (revised 7/14/21) documented, in part: Policy: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls. Overview: Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls .Fall Defined: Fall refers to unintentionally coming to rest on the ground, floor . On 3/21/22 at approximately 11:02 AM, R69, who is a double above the knee amputee, was observed sitting in a wheelchair in their room. A scar was noted on their left forehead. When asked about falls in the facility, R69 reported that in January they were in their wheelchair in the hallway, fell forward, hit their head, and had to go to the hospital and received several stiches to their forehead and had some bruising. The resident later reported that a CNA had attempted to pull his shorts up when he was in his wheelchair causing him to fall forward out of the wheelchair on to the floor. The resident stated that his wheelchair was not locked and considered the incident an accident. A review of R69's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: acquired absence of right and left leg above knee, peripheral vascular disease, diabetes type II and hypertension. A review of the resident Minimum Data Set (MDS) noted the resident was cognitively intact and was not able to ambulate on their own. Continued review of the resident's clinical record documented, in part, the following: A progress note dated 1/25/22: Resident was in hall in his w/c. The CNA (Q) was pulled <sic>up his pants from the back of the w/c and resident fell forward onto the floor. Turned over to his back by nursing and found laceration to let side of forehead and abrasions to left hand knuckles. He was alert and oriented but very upset .EMS was called .to transfer to (name redacted) Hospital. Hospital Records dated 1/25/22: ED (emergency department) .Medical Decision Making: Patient .evaluated after a fall with forehead laceration .laceration was sutured, 9 sutures placed .Patient was instructed to return in 5 days for removal of stitches . An Encounter (physician) note dated 1/26/22: .Visit Type: Follow Up .Recent fall with laceration to the left forehead, extensive bruising laceration to the nose status post trip to ER and sutures .Patient .fell forward while pulling his pants up .he was restless and had to be sent out to the ER .Patient's face is severely bruised and has traumatic ecchymosis (discoloration of skin) . A review of the facility Incident and Accident (IA) report revealed: .Person Involved (R69) .Date of Occurrence 1/25/22 .Type of A/I: fall: Location of Injury: Laceration of L side of forehead, bleeding and swelling .sitting in hallway outside of room .Describe the nature of the Accident .Resident fell out of w/c while CNA Q was in the back of w/c and was pulling his pants up and he fell forward onto the floor- face first. Urinated on the floor @ time of fall .send to hospital .Post Fall Evaluation: 9 bil (bilateral) leg amputee .Resident was up in wheelchair in hallway, wanted shorts adjusted, fell forward as assistance was provided . *It should be noted that the facility reported that there were no further investigation documents other than the I/A. On 03/23/22 at approximately 9:53 AM, an interview was conducted with CNA Q. CNA Q reported that on the morning of 1/25/22, R69 was in his w/c in the hallway and observed that his shorts were not fully pulled up and his stomach, that was large, was showing. She then asked R69 if he wanted his shorts pulled up and he told her that he did. CNA Q stated that she went behind the resident's w/c and pulled up his shorts and at the same time the resident fell forward and hit his head on the floor. When asked if she had received training on fall prevention and was familiar with R69, a double amputee patient, CNA Q stated that she did receive fall prevention training and often was assigned to R69. When asked if pulling a resident's shorts from behind, especially for a double amputee resident was appropriate, CNA Q stated that she probably should have asked for assistance or used a gait belt to ensure he remained stable in his w/c. On 3/23/22 at approximately 10:38 AM, an interview was conducted with the Director of Nursing (DON). When asked about R69's fall, the DON stated that if the CNA Q had asked for assistance, the fall could have been prevented. On 3/23/22 at approximately 03:23 PM and interview was conducted with Physical Therapist Manager (PT) R regarding R69's balance and the fall that occurred on 1/25/22. PT Manager R stated that as the resident is very top heavy and an amputee, the CNA should have requested assistance to ensure the resident's safety.