**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2597303.Based on observation, interview, and record review the facility failed to ensure appropriate supervision and assistance was provided during toileting for 1 (Resident #503) of 3 residents reviewed for falls resulting in a head injury, fracture of a patella (kneecap), and pain.Findings include:Resident #503:Review of the facility's facility reported incident report for Resident #503 (R#503), submitted 7/30/2025, stated, .Incident Summary. Staff entered resident's (R#503) bathroom and observed resident on the floor; resident sent to emergency room.Investigation Summary. Individual(s) Involved: (R#503) (Resident) A [AGE] year-old female.has diagnoses of Alzheimer's (form of dementia; brain disorder that destroys memory/thinking skills).abnormalities of gait (manner of walking or moving on foot) and mobility, unsteadiness on feet.chronic pain.history of falls, dementia (unspecified severity; without behavioral/psychotic/mood disturbance; without anxiety). restlessness and agitation.anxiety.She is dependent on staff x2 (two staff members) for all Activities of Daily Living (ADLs) and is unable to make her needs known. A BIMS (Brief Interview for Mental Status) score was attempted on July 1, 2025 but was unable to be completed due to (R#503) cognitive decline (This reflected R#503 had severe cognitive impairment). Summary of Events On July 29, 2025, (Registered Nurse (RN) R) was administering medications when she heard a loud noise coming from (R#503's room number). Upon entering the resident's room, (R#503) was observed lying sideways on the floor in front of her bedside commode. (R#503) was transferred to [Hospital Name] for evaluation. (R#503) re-admitted to the [Nursing Facility] on July 30, 2025 where it was revealed she suffered a fracture of her left patella (kneecap). Statements (Certified Nurse Aide (CNA) H) was requested by R#503's Guardian (family member responsible for making decisions due to the resident's inability to do so), (R#503)'s daughter, to place the resident on her bedside commode and then transfer her back to her recliner when toileting was completed. (R#503) had not successfully voided (evacuated urine and/or feces) by the time CNA H completed her shift, so information was exchanged during shift rounding that (R#503) remained on the toilet until voided was successful. As (RN R) was completing her medication administration, she heard a loud noise coming from (R#503's) room and upon arrival, observed (R#503) lying sideways on the floor.On-call physician was notified who ordered resident be transferred to the emergency room for evaluation.When (date and time) did the problem occur? 07/29/2025 10:00 PM (other facility documentation included below indicated the fall was at 6:50 PM or 7:00 PM).During an observation on 9/3/25 at 10:16 AM, Resident #503 was in her room, lying in her bed flat on her back, and was non-verbal.During an interview on 9/3/25 at 09:00 AM, Director of Nursing B reported Resident #503 had been left alone on the bed side commode (toilet) prior to the fall incident on 7/29/25 and should not have been.During an interview on 9/4/25 at 9:31 AM, Resident #503's Guardian X reported she had never wanted her mom (Resident #503) left alone on the commode. Guardian X confirmed her mom had been confused and was confused and non-verbal during her stay at the facility. Guardian X reported her mom is unable to use a call light and felt had someone been in the room with Resident #503 while she was on the bed side commode she would not have fallen.During an interview on 9/4/25 at 11:40 AM, Certified Nurse Aide (CNA) H was asked if Resident #503 should have been left on the bed side commode alone and stated, No. CNA H reported she didn't feel Resident #503 was left unattended because the door was open while she was on the commode and staff were huddled outside Resident #503's room for shift change report. CNA H confirmed no one was within arm's reach of Resident #503 while she was on the bed side commode on 7/29/25 before the fall happened.During an interview on 9/4/25 at 8:52 AM, Certified Nurse Aide (CNA) K reported she would never leave Resident #503 alone on the bed side commode if she had been caring for her. CNA K reported Resident #503 required two staff assistance for toileting and once transferred onto the commode one staff member should have stayed with the resident to prevent a fall. CNA K confirmed Resident #503 had dementia, was unable to use her call light to request help, and there was no reason a nurse or CNA shouldn't have been with #503 during toileting on the commode.During an interview on 9/4/25 at 8:58 AM, Certified Nurse Aide (CNA) N reported she would never leave a cognitively impaired resident, which she confirmed Resident #503 was, alone on a commode (toilet). Review of Resident #503's Investigation Report (a packet/file of information) for the 7/29/25 fall with fracture stated, Fall with injury events and conclusion: Resident Information.Cognitive Status: Severely impaired cognition.Safety Awareness: Poor; high fall risk.Location: Resident's (Resident #503) room.Type of Incident: Unwitnessed fall.Activity at Time of Fall: Using bedside commode.Description of Event.During routine medication administration, the nurse (Registered Nurse R) heard a loud noise from (Resident #503's) room.Upon entering, (Resident #503) was found lying sideways on the floor, face down.Hematoma (closed wound where blood collects in a space) observed on the right side of forehead.Findings: Fractured left patella (kneecap).Closed head injury.Root Cause Analysis.(Resident #503) attempted to move forward on the BSC (bed side commode) without staff assistance.Her (Resident #503) cognitive impairment and poor safety awareness contributed to the fall.Date/Time Incident Occurred: 7/29/2025 07:00 PM.Witness Statement.Name and Title of person being Interviewed: (Certified Nurse Aide (CNA) H).Date and time of Interview: 7/30/25 0800 (8 AM).Statement.(Resident #503's Guardian X) was in too see her mother (Resident #503) and requested that I put on the commode and let sit and then place her in her recliner and feed her dinner. Requested (CNA H) if can't finish to have the next shift complete the task. Myself (CNA H) and (CNA N) placed (Resident #503) on the commode and repositioned her. I (CNA H) gave report to (Registered Nurse R) reported not to leave her (Resident #503) alone. We were trying figure out staffing and I went back and gave report to all the staff present for follow up.Review of Resident #503's post (after) fall hospital paperwork, dated 7/29/25, stated, Chief Complaint: FALL.DIAGNOSIS.1. Closed (broken bone that doesn't break through the skin) nondisplaced (fracture occurs to the bone but it says in normal position/alignment) comminuted (bone that is broken in at least two places) fracture (break) of left patella (kneecap).2. Closed head injury.Female (Resident #503) presents for unwitnessed fall.She does have a hematoma to the right forehead.There is tenderness to the left knee with some erythema (redness of skin) and swelling.Daughter at bedside indicates that patient (Resident #503), her mother is nonverbal due to advanced dementia.XR (x-ray) Left Knee.Indication: left knee pain/swelling, unwitnessed fall off toilet. Review of Resident #503's progress note, dated 7/30/25 at 06:03 AM, stated, (Resident #503) returned to facility.Patellar (kneecap) fracture to left leg, knee mobilizer in placed. 1 week follow-up appointment recommended.Review of Resident #503's progress note, dated 7/30/25 at 08:06 AM, stated, Acetaminophen Extra Strength (pain relief medication).Give 2 tablet by mouth every 8 hours as needed for Pain.Review of Resident #503's Pain Level Summary, dated 7/1/25-8/2/25, indicated a pain level of zero (0-10 point scale; 0 meaning no pain and 10 meaning highest level of pain) consistently from 7/1/25 through 7/28/25 (day before the fall). On 7/30/25 (after the fall) Resident #503's pain score was noted to be a 3 at 08:06 AM, a 5 at 4:45 PM on 8/1/25, a 3 at 5:12 PM on 8/1/25, a 2 at 1:15 AM on 8/2/25, and 1 at 7:34 AM on 8/2/25.Review of Resident #503's Nursing: Fall Checklist, dated 7/30/25, stated, Date of Fall: 7/30/2025.Time of Fall: 18:50 (6:50 PM).What did the guest/resident say they were trying to do just before they fell? .Aphasia (communication disorder) Mumbles.Time last toileted and/or changed: 6:50 PM.Root Cause of this Fall:.Toileting Status. Review of Resident #503's fall risk assessment, dated 7/1/25, stated, .Confusion most/all of the time.Routinely incontinent (bowel and/or bladder).Moderate/severe unsteadiness - requires physical assist.Safety Awareness: .Lack of understanding of physical and cognitive limitations.Review of Resident #503's cognition care plan, revised 07/02/2025, stated, The resident (Resident #503) has impaired cognitive function/dementia or impaired thought process r/t (related to) Alzheimer's, Dementia.Staff to anticipate her (Resident #503) needs aeb (as evidenced by) non-verbal communication, provide safety and comfort. Review of the facility's Activities of Daily Living (ADL) policy, revised 12/7/2023, stated, Appropriate care and services will be provided for residents who are unable to carry out ADL independently.including appropriate support and assistance with.Elimination (toileting).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00150232. Based on interview and record review, the facility failed to ensure residents received quality care based on professional standards for 1 (Resident #103) of 3 residents reviewed for unwitnessed falls, resulting in a delay in identifying a change in condition and treatment for multicompartmental acute intracranial hemorrhage (brain bleed). Findings include: Resident #103 Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 10/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #103 was moderately cognitively impaired. Review of Resident #103's Care Plan revealed, (Resident #103) is at risk for falls r/t (related to ) dementia, requires assist with ADL's (activities of daily living), skin impairment to heel with recommended cushion boots, new environment, seizure disorder, psychoactive medication use, hx (history) of falls, hx of intracranial hemorrhage, hx of alcohol abuse. (Resident #103) becomes restless while in bed, at times, attempting to stand. Date initiated: 8/14/24. Interventions: Anticipate needs. Date initiated: 8/14/24 . Bed in low position when resident is in bed. Date initiated: 9/25/24 .Call light within reach. Date initiated: 8/14/24 .Encourage Resident to remain in common areas while awake. Date initiated: 8/16/24. Encourage resident to stay out in common area until HS (night time) meds given. Date initiated: 9/25/24. Have commonly used articles within easy reach. Date initiated: 8/14/24. Keep bed at transfer height. Date initiated: 9/30/24. Low bed at all times. Date initiated: 8/14/24 .Offer resident frequent reminders to use call light during interactions. Date initiated: 8/14/24 . Offer toileting frequently throughout the day. Date initiated: 9/20/24 . Review of Resident #103's Fall Risk Evaluation dated 12/26/24 indicated that Resident #103 was confused most/all of the time, had a history of 3 or more falls within the last 3 months, was routinely incontinent, had adequate vision, was moderate/severely unsteady and required physical assistance. Resident #103 was impulsive, lacked understanding of physical and cognitive limitations and forgot or did not always use assistive devices. Resident #103 took three or more medications which increased risks for falls and Resident #103 had 3 or more predisposing diseases and conditions which increased risk for falls . Review of an Incident Report submitted by Nursing Home Administrator (NHA) A dated 1/12/25 revealed, . Details: (Resident #103) was seen in the bathroom laying on his back with an abrasion on his forehead, he was able to tell staff that he didn't hit his head, but he had a change in condition and staff notified on-call physician and an order was to send to local hospital. (Resident #103) returned with a hemorrhage. A full investigation will follow . Review of Resident #103's Progress Note dated 1/10/2025 and documented by Registered Nurse (RN) HH revealed, Patient(Resident #103) was observed laying on the floor in restroom/ bedroom. This nurse was informed by CNA (Certified Nursing Assistant) that patient fell. Patient wheelchair was in the hallway. Patient was observed in a supine position (lying on back) face upward. Patient was assessed for injury and vital signs obtained. Patient has abrasion noted to bil (bilateral) elbows, and abrasion noted to left knee x2. Patient was transferred from floor to bed via hoyer. Patient is denying hitting head and pain and discomfort at this time. Provider notified of this fall along with DON (Director of Nursing). This nurse attempted to reach out to patient family unable to reach. Patient was treated with schedule pain medication. Patient appears to be in no pain or discomfort at this time. Provider gave orders to dress the abrasion with xerofoam (type of sterile gauze) and cover with Mepliex (type of dressing) foam change QOD (every other day) until Monday when wound staff can follow up. Review of Resident #103 Progress Note dated 1/11/24 at 07:54 AM revealed, eMAR - Administration Note. Note Text: Assess Resident for Pain Every Shift every shift for Pain. Facial grimacing, he stated I hurt all over . Review of Resident #103 Progress Note dated 1/11/2025 at 9:27 AM and documented by Licensed Practical Nurse (LPN) EE revealed, Incident Note: Note Text: Res had a fall yesterday on second shift, he was complaining of generalized pain this morning, routine Tylenol and Ultram given as ordered, but he is denying pain at this time but facial grimacing, BP (blood pressure) is high 184/67, will retake, he normally eats breakfast and drinks his coffee, but he refused. DPOA (durable power of attorney) notified via phone call. Review of Resident #103's Progress Note dated 1/11/2025 at 9:28 AM and documented by LPN EE, revealed , Incident Note: Note Text: Abrasions noted to his forehead, and some blood on the carpet by his bed. Review of Resident #103's Progress Note dated 1/11/2025 at 11:01 AM and documented by LPN EE revealed, Note Text: still facial grimacing but denying pain, routine Tylenol and Ultram is coming up soon, BP is still high 159/84. Review of Resident #103's Progress Note dated 1/11/2025 at 12:23 PM and documented by LPN EE revealed, Note Text: 170/80, staff had to assist him with eating, this is new, he normally will get himself out of bed but has not done that either since the start of shift. He continues to deny pain but facial grimacing and frowning noted. Review of Resident #103's Progress Note dated 1/11/2025 at 1:51 PM and documented by LPN EE revealed, Note Text: spoke to his DPOA again for recent updates, not able to feed himself at lunch, did try to get of bed but staff helped him back quickly, he ate poorly at lunch with full staff assistance. continues to rest in bed. Review of Resident #103's Progress Note dated 1/12/2025 at 8:04 AM and documented by LPN EE revealed, Note Text: . resident is not alert as usual, bp is still high 173/68, he is sleeping a lot, total care now, this quite a change, eating less and coughing with meals and drinks. Review of Resident #103's Progress Note dated 1/12/2025 at 10:39 AM and documented by LPN EE revealed, Note Text: Hey (Name redacted- Facility Physician Assistant C, running a low-grade fever of 99.3, cold compress applied. 157/67, P-88, O2-93%RA (oxygen saturation on room air), res (respirations) is 20, occasional coughing noted as well. Family is asking for some tests. Review of Resident #103's Progress Note dated 1/12/2025 at 10:59 AM and documented by LPN EE revealed, Note Text: On call provider (Physician Assistant C), ordered stat chest x-rays to views, order placed . Review of Resident #103 Progress Note dated 1/12/2025 at 12:12 PM, and documented by LPN EE revealed, Note Text: ADON (Former Assistant Director of Nursing) D asked for him to be sent out, and family agrees, sending out to (local hospital) Review of Resident #103's Progress Note dated 1/12/2025 11:11 PM and documented by LPN EE revealed, Note Text: The ER discharging nurse reported that res (Resident #103) has significant brain bleed, family declined treatment and want Hospice/comfort, (local hospice) Hospice nurse is coming in early in the morning to meet with family. Review of Resident #103's Hospital Records dated 1/12/25 revealed, . Chief Complaint: Fall Injury (Unwitnessed fall on Friday evening, did not seek medical attention at that time. Staff reports that patient is more somnolent (drowsy) since either yesterday or this morning, is normally confused but alert and conversative.) . Treatment Plan: Patient seen and examined by myself as well as my attending physician for a chief complaint of a fall on Friday for which he did not seek medical attention with increased somnolence/decreased mentation over the last 24 to 48 hours. At bedside patient Semi-Fowler's (lying on back with head of bed elevated) in bed, nontoxic-appearing, mumbling, not answering questions appropriately, not following commands. Vital signs assessed and patient was mildly hypertensive 180/100 . Physical exam findings did reveal a contusion over patient's left and right forehead with no deformity or crepitus or overlying laceration. Patient also had a significant number of bandages over all major joints with various dates from multiple falls over the last couple weeks no evidence of joint instability in extremities .Based on patient's initial presentation my initial clinical suspicion included intracranial hemorrhage from recent fall .I independently interpreted patient's head CT (computed tomography scan) and did appreciate what appears to be a significant intracerebral hemorrhage with no obvious fracture or dislocation . Given the protracted nature of time since the onset of symptoms and unsure disposition, patient's DPOA( durable power of attorney)contacted who is his eldest daughter and states the patient is currently a DNR (Do Not Resuscitate) and that she would like to discuss the case with her younger sibling to decide how to proceed whether or not to bring patient home for comfort care or if they would like patient admitted with more aggressive measures .Patient's DPOA/eldest daughter did contact me and states after discussing the case with her sister they do believe that they would like to have patient brought back to the sending facility and would be contacting hospice . Shortly after updating patient's daughter on the plan nursing alerted me that patient had fallen out of bed and landed on his face resulting in a significant laceration to the forehead and bridge of the nose. Patient was cleaned up and assisted back to bed by nursing. Given the goals of care as well as known intracranial hemorrhage no repeat imaging was performed based on goals of care wishes. Patient's lacerations were closed without complication; . During an interview on 2/19/25 at 12:52 PM, CNA Z reported that she was the staff member that had found Resident #103 after his fall on 1/10/25. CNA Z reported that she had gone to check on Resident #103 when he had not arrived in the dining area for dinner and she found him lying on the bathroom floor. CNA Z was unable to report the last time that she had checked on Resident #103, so she did not have any idea how long Resident #103 had been lying on the floor. CNA Z reported that she recalled Resident #103 had some blood on both of his legs, but she did not remember if he had any abrasions or bumps on his head. During an interview on 2/19/25 at 9:10 AM, RN HH reported that she was the nurse caring for Resident #103 the night that he fell. RN HH reported that she was notified by CNA Z that Resident #103 was on the floor and she went to assess him. RN HH reported that she did not notice any abrasions on Resident #103's head (as found in the hospital report). RN HH reported that she notified the provider on call, and the Director of Nursing (DON) about Resident #103's fall. RN HH reported that she had not noticed any changes with Resident #103 after his fall, but that she had never worked with him before, so she was not familiar with his baseline. During an interview on 2/19/25 at 1:17 PM, CNA BB reported that she had cared for Resident #103 after his fall on 1/10/25 and that Resident #103's assistance needs had increased to requiring total assistance from staff. CNA BB confirmed that Resident #103 was independent with tasks such as eating and dressing prior to his fall. CNA BB reported that this was a significant change for Resident #103. During an interview on 2/19/25 at 11:23 AM, LPN EE reported that she was the nurse that cared for Resident #103 on 1/11/25 and 1/12/25 after his fall. LPN EE reported that she had noted that Resident #103 appeared to be in pain, and she noticed an abrasion on his head near his hairline. LPN EE confirmed that Resident #103's blood pressure had increased since his fall, he was not eating, and requiring total assistance from staff, which was a change in condition for him. LPN EE reported that she had notified the on call provider, Physician Assistant (PA) C of the changes she had noticed with Resident #103. LPN EE reported that PA C had instructed her to order a chest x-ray since Resident #103 had a cough, and continue to monitor Resident #103. LPN EE reported that she was not sure if Resident #103's change in condition was related to his fall, but she did feel like Resident #103 would have benefited from going to hospital. LPN EE reported that she did not advocate to PA C for Resident #103 to be sent to the hospital, because he was the provider and she felt like she could trust his judgement. LPN EE reported that she did not know if PA C was aware that Resident #103 had an unwitnessed fall. LPN EE confirmed that PA C was not at the facility to assess Resident #103, and that the provider relied on nursing assessments and communication to make treatment decisions. During an interview on 2/19/25 at 10:56 AM, Former Assistant Director of Nursing (ADON) D reported that she was the staff member that instructed LPN EE' to send Resident #103 to the hospital on 1/12/25. Former ADON D reported that since she was the nursing manager, she had been included on all communication messages between nurses and PA C. Former ADON D reported that on 1/12/25 she had checked the messages from her home and when she read the communication between LPN EE' and PA C' about Resident #103, she was shocked that Resident #103 had not been sent out to the hospital yet. Former ADON D reported that from the messages she had read it was clear that Resident #103 was experiencing a change in condition and likely a closed head injury based on the symptoms. Former ADON D reported the symptoms she felt were likely related to a closed head injury included increased blood pressure, decline in ADL's, sleepiness, and an increased temperature. Former ADON D reported that she immediately called LPN EE and told her to send Resident #103 to the hospital. Former ADON D reported that she felt that LPN EE and PA C missed the change in condition for Resident #103, and that he should have been sent to the hospital as soon as changes were noted since Resident #103's fall was unwitnessed and he had an abrasion on his forehead, so it was likely that he had hit his head. During an interview on 2/19/25 at 2:13 PM, PA C reported that he was the provider on call on 1/11/25 and 1/12/25. PA C confirmed that he had been made aware that Resident #103 had a fall on 1/10/25, and that Resident #103 had an abrasion on his head and he did not eat breakfast. PA C reported that he was not aware of Resident #103's increased blood pressure. PA C' reported that he had not been contacted on 1/12/25. This writer read LPN EE's progress notes from 1/11/25 and 1/12/25 to PA C and queried as to what his clinical judgement was for the symptoms noted in the progress notes. PA C reported that the symptoms noted in LPN EE 's progress notes on 1/11/25 and 1/12/25 were all potential symptoms of a closed head injury. PA C reported that if he had been aware that Resident #103 was experiencing a change in condition and decline after a fall, he would have requested a virtual health visit to assess Resident #103, and then send him to the emergency department if he felt like it was necessary. PA C reported that he relied on the nurse's communication of changes to make treatment decisions because he was not in the facility to assess residents. On 2/19/25 at 1:11 PM, this writer requested a copy of the messages sent between LPN EE and PA C. NHA A reported that the messages were not available, and were deleted after 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #101: Review of an admission Record revealed Resident #101 was a male with pertinent diagnoses which included Alzheimer's disease, heart failure, muscle weakness, repeated falls, difficulty in walking, spinal stenosis (narrowing of one or more spaces within your spinal canal), and dislocation of T10/11 thoracic vertebra (middle segment of the spine have moved out of their normal position). Review of current Care Plan for Resident #101, revised on 1/29/25, revealed the focus, .At risk for falls and safety risks due to Alzheimer's disease with impaired cognition, history of repeated falls, impaired balance, weakness, potential medication side effects, visual impairment related to glaucoma, congestive heart failure, cardiomyopathy ( ), anemia (low iron in the blood), protein calorie malnutrition, hx (history) syncope (fainting). (Resident #101) has impaired safety awareness and frequently attempts to self-transfer without assistance . with the intervention .Assist to chair and high traffic area when awake as resident allows .bed in low position when resident is in bed .call light within reach .Encourage to transfer and change positions slowly .Have commonly used article within easy reach .Provide assist to transfer and ambulate as needed .Reinforce need to call for assistance .Therapy evaluation and treatment per orders . Review of admission Evaluation dated 1/8/25 at 4:06 PM, revealed, Resident #101 had occasional confusion, 1-2 falls in the last 3 months, balance/unsteady while standing, transferring and/or walking - moderate/severe unsteadiness - required physical assist. Resident #101's safety awareness was attempts to self-transfer or ambulate when not recommended to do so, impulsive, lack of understanding of physical and cognitive limitations. The baseline care plan for Resident #101 was minimize risk for falls. Resident #101 was screened for transfers which revealed resident was not able to stand pivot transfer with contact guard assist or less, was not able to move from supine to sitting, and required manual, supervised transfers with a gait belt. Requested and reviewed a list of falls for the last 30 days which revealed, Resident #101 had 4 unwitnessed falls. Review of Incident Reports dated 1/11, 1/14, 1/19, 1/24, 2/11, and 2/14 revealed immediate interventions were not implemented for Resident #101's safety as he was considered a high fall risk and required additional supervision to prevent further falls Review of Resident #101's care plan revealed the care plan was not updated after each fall incident to aid in the prevention of further falls. Review of History and Physical dated 1/9/25 at 00:00 AM, revealed, .Patient required sitter during hospital admission due to impulsivity, confusion, and behaviors . Review of No Type Specified note dated 1/9/2025 at 11:08 AM, revealed, .Attempting to stand up, looking for his car, lots of redirections, called his significant other, they are currently talking on the phone . Note: This was not included as an intervention for Resident #101's care plan. Review of Nursing -Progress Note dated 1/11/2025 at 11:54 PM, .Patients' roommate put on call light for assistance. Staff went into room to answer call light and observed patient on the floor sitting on his buttocks with feet in front of him and back against the wall next to the bathroom door. Patient was barefoot and walker still next to bed. Patient stated he had just gone to the bathroom and lost his balance and fell. Nursing assessment completed, no injuries or bruises noted. Neuro checks implemented, Vss (vitals) BP134/76 P (pulse) 88 R(respirations)16 T (temperature) 97.60296% rm air. On call provider and nursing team notified. Patient is currently resting in bed with no known concerns at this time . Note: No intervention to provide frequent rounding, signage to remind resident to use his walker, or staff increased requests to assist to restroom were not included as interventions for Resident #101's care plan. Review of Resident #101's care plan did not include an intervention for grippy non-slip socks or footwear. Review of Fall-Risk Evaluation dated 1/12/25 at 00:22 AM, revealed, Resident #101 had occasional confusion, 1-2 falls in the last 3 months, poor/impaired vision, and he was impulsive, forgets or does not always use assistive devices, lack of understanding of physical and cognitive limitations, and attempted to self-transfer. Review of Nursing -Progress Note dated 1/12/2025 02:05 AM, revealed, .Patient continues to try and self-transfer out of bed throughout the night. Patient was asked what he needs. Patient stated, I don't know I was trying to get a sheet!! Patient had sheet and blanket covering him. Staff asked patient was he cold and needed extra blankets? patient begin to yell at staff saying, leave me alone! Patient reminded once again to use call light and to not get up without assistance . Review of Nursing -Progress Note dated 1/15/2025 at 01:15 AM, revealed, .At 2300 (11:00 PM) Assigned Nurse went to do rounds, Patient was observed lying on the floor next to his sink and bathroom door. The bathroom door was halfway open with lightbulb on. Patient's Head was against the bottom of the bathroom door, legs out in front of him, sitting on his buttocks. Patient bed was in the low position did not see walker in room. Wheelchair was on the other side of room. Patient had on pjs with regular socks. Patient stated that he doesn't remember what he was doing and asked me to go get the neighbors with the truck to help him up. nursing assessment completed patient complained of pain in his lower back. Patient stated that he cannot sit up and kept falling over could not sit straight up. On Call provider notified and patient sent out to (Local Hospital) for further eval. VSS BP99/72 P80 R18 0296% rm air. Neuro checks implemented . Review of Nursing -Progress Note dated 1/15/2025 at 06:47 AM, revealed, .This nurse received report from ER (Emergency Room) Nurse (First Name) stating that resident is on his way back from (Local Hospital) ER. ER Nurse stated that resident has a T3 & T8 fracture. ER Nurse states that patient has a follow up appointment in a few weeks but at this time it is nothing they can do for the fractures and will let them heal on their own and have patient continue therapy . Review of Progress Note for (Local Hospital) Emergency Department dated 1/15/25 revealed, .HPI: The patient is a [AGE] year-old male presents emergency depart chief complaint of fall . States that today he was found down in the bathroom. Unsure of the mechanism. The patient is altered at baseline but able to answer basic questions. States that he does not remember any of the symptoms prior to the fall. Does not remember if he hit his head or not. Not on any blood thinners. Main complaint is lower back pain .Musculoskeletal: Comments: Lower back tenderness. Full range motion of upper and lower extremities. No reproducible tenderness over extremities .Assessment/Plan: DIAGNOSIS at time of disposition: 1. Fall, initial encounter .2. Closed fracture of third thoracic vertebra, unspecified fracture morphology, initial encounter (HCC) .3. Closed fracture of eighth thoracic vertebra, unspecified fracture morphology, initial encounter (HCC) .CT scans .The scans revealed fractures of the T3 and T8 vertebrae . Review of No Type Specified dated 1/15/2025 at 08:02 AM, revealed, .CNA observed res standing and walking in his room unassisted, staff assisted him to his wheelchair and back into the dining room . Review of Nursing -Progress Note dated 1/16/2025 at 11:12 PM, revealed, .Res is attempting to transfer himself all the time, not using the call light for help . Review of No Type Specified dated 1/16/2025 at 06:50 AM, revealed, .(Resident #101) was alert and restless during the evening. He wheeled himself from the common area of the unit back and forth to his room several times.(Resident #101) was noted transferring himself from his wheelchair and standing in his room. He was redirected by staff and encouraged to ask for help many times during the evening.(Resident #101) would not wait for staff to assist him. He continued to take himself back to his room each time staff tried to keep him within sight for the purpose of his safety due to his poor safety awareness .(Resident #101) continued to attempt to self- transfer late during the night. Staff had to visit his room frequently to check to make sure he was safe. VSS. Neurological assessment is WNL (within normal limits) .(Resident #101) did not complain of pain. This Nurse suggests placing a tab alarm on Resident due to his restlessness, poor safety awareness, and frequent falls . Review of Incident Note dated 1/19/2025 at 2:06 PM, revealed, .Resident was observed laying on the floor in his room. He was laying on his right side, and he was holding his head up. No injury noted as of now. Voice message left for significant other, on call supervisor notified via phone call, on call provider notified via tiger text message. Alert charting and neurological assessment initiated . Review of Incident Report dated 1/24/25 at 9:30 PM, revealed, .At about 9:30 PM, res was observed laying on floormat by his bedside .Level of pain: 4 . Review of Nursing - Progress Note dated 1/25/2025 at 06:05 AM, revealed, .Patient continued to self-transfer out of bed during the night. Patient is impulsive and does not put on call light to have staff assist him to the bathroom. Patient was given a urinal to keep at bedside but often forgets to use it and stills try to self-transfer himself out of bed . Review of Nursing - Progress Note dated 1/27/2025 at 11:22 PM, revealed, .Urine sample obtained, called (Local Hospital) lab for pick up . Review of Incident Report dated 2/11/25 at 11:43 AM, revealed, .At 1130, (Resident #101) was observed sitting in the hallway with legs stretched out with his back leaning against the wall. He was next to his wheelchair. Had grippy socks on .Res. stated help me please . Review of IDT dated 2/14/2025 at 11:18 AM, revealed, .Pt (patient) was observed on the matt next to his bed laying on the floor. Resident had on his gripper socks . Note: Fall mat was not included as an intervention in Resident #101's care plan. In an interview on 2/19/25 at 12:15 PM, Registered Nurse (RN) CC reported when a resident had a fall, she would go to them to assess, take vitals, perform ROM (if necessary), ask if the resident had pain or hit their head, if necessary start neuro checks on the resident. RN CC reported then you would try to determine why the fall occurred and create interventions to assist with preventing the incident from happening again. RN CC reviewed the green folder for Falls at the nurse's station, which contained a document named Falls Risk management checklist .3. Immediate interventions to ensure they don't fall again? When queried RN CC reported Try to come up an intervention so they don't repeat with the same cause of the fall. In an interview on 2/19/25 at 12:36 PM, Unit Manager (UM) DD reported the nurse would create a risk management report for an incident and the nurse reviewed the care plan, update it with an intervention, and if there was not a focus already one would be created with interventions. UM DD reported an immediate intervention would be created with each fall. UM DD reported when a risk management report was generated additional tabs would be opened for additional assessments such as a fall risk evaluation. She indicated there was a point in the risk management report where the nurse was able to add witness statements from the staff present. UM DD reported the care plan were able to be updated by the nurses. UM DD reported for residents who were impulsive and had multiple falls, the facility would develop interventions to help keep that individual safe such as, possibly the resident needed a different chair. For example, when a resident utilized a broda chair, they may not be comfortable in it and attempt to get out of it. For residents who wander, they may need a lot of redirection, for those who forget to use their walkers -reminders to use their walkers. The staff on the floor needed to continue re-orienting the residents, keep reinforcing the use of the walker. Staff would need to have eyes on the floor, and when residents were in their rooms as well by looking in on them frequently. The staff should be walking the hallway, laying eyes on the residents, redirecting them, possibly have the residents come out and participate in activities, encourage them to come out of their rooms, do activities with the residents or give them something to work on like a puzzle, cards, or just talking with the residents. UM DD reported the staff should be making rounds on the floors, monitoring residents as they were the first line on the floor. In an interview on 2/20/25 at 11:09 AM, Director of Nursing (DON) B reviewed Resident #101's care plan and reported the first intervention noted in the care plan was dated 1/16/25. DON B reported there were not interventions developed for Resident #101 following each fall. She reported an immediate intervention was to be created after each fall to ensure the resident's safety and minimize the risk for injury. DON B reported the falls were reviewed each morning during the morning meeting with all the disciplines involved for different perspectives for possible reasons for falls, and they would review the interventions to determine if the immediate intervention was a good intervention or revise the care plan. On 2/20/25 at 11:42 AM, DON B reported antitippers was the initial intervention for Resident #101 at entry for a baseline care plan. Resident #108: Review of an admission Record revealed Resident #108 was a female with pertinent diagnoses which included right artificial hip joint, joint replacement surgery, muscle weakness, difficulty in walking, necrosis of the bone (loss of blood supply to the bone causing it to die) and history of falling. Review of current Care Plan for Resident #108, revised on 2/11/25, revealed the focus, .At risk for falls due to total right hip replacement . with the intervention .Provide assist to transfer and ambulate as needed . Review of current Care Plan for Resident #108, initiated on 2/10/25, revealed the focus, .Resident has an ADL self-care performance deficit related to: activity intolerance, ADL abilities will fluctuate with therapy staff and nursing staff, limited mobility . with the intervention .Locomotion: x1 assist x 100' with fww (four wheeled walker) .Toilet Use: 1 person assist with fww .Transfer: 1 person assist with fww . Review of Physical Therapy: PT Evaluation & Plan of Treatment dated 2/8/25, revealed, .Reason for Therapy: chronic h/o (history of) arthritis underwent s/p R THA (total hip arthroplasty), presents with R (right) LE (lower extremity) weakness, poor dynamic balance (ability to maintain stability while moving your body), difficulty standing, walking and cannot walk for any length of time .Fall Predictors: Inadequate postural control, inadequate ankle dorsiflexion (movement of the ankle joint where the foot is raised towards the shin), reduced quad strength (thigh muscles) and weak trunk and hip extensors . In an interview on 2/18/25 at 12:57 PM, Resident #108 reported when she called staff for assistance to use the restroom, Certified Nursing Assistant (CNA) E responded to her request. Resident #108 reported asked her for assistance to get to the bathroom and Resident #108 reported CNA E informed her she was here for therapy, she needed to learn to be independent, and she just stood there watched her struggle. Resident #108 reported she just needed a little help with her leg and she needed to get to the bathroom. Resident #108 reported she did not assist her with transferring out of her bed either. Resident #108 reported she was in pain and she was concerned for her safety. In an interview on 2/20/25 at 09:15 AM, Director of Therapy O reported Resident #108 came in as a one assist with ambulation, transfers, toileting. Director of Therapy O reported one assist was with one staff member with a gait belt for ambulation, transfers, and toileting with contact and steady hand to stabilize Resident #108 if she needed it. In an interview on 1/19/25 at 10:35 AM, Licensed Practical Nurse (LPN) II reported the resident's information - how they transfer, ambulation, the basics of to care for them was on the communication board. LPN II reported the information was entered prior to the resident coming, also the nurse at the hospital gives a nurse to nurse report. LPN II reported all staff have access to the communication board and she would also speak to the CNAs to share information with them as well. CNA R was present, and she reported the CNAs would also look at the Kardex as that would tell them how to care of the resident. In an interview on 2/20/25 at 11:09 AM, Director of Nursing (DON) B reported the admission process was a current work in progress. DON B reported the baseline care plan was created from the admission assessment. DON B reported the care plan created a Kardex for the staff to refer to. DON B reported the nurse created the care plan, she would give report to the CNA, after that can review the Kardex and update that form for them. In an interview on 2/20/25 at 11:09 AM, Director of Nursing (DON) B reported a one person assist would require the staff to provide support or supervision to the resident. DON B reported with a resident who had a recent join surgery the expectation was for staff to provide support to the resident for safety. This writer attempted to contact CNA E who did not reach back prior to exit from the facility. This citation pertains to intake MI00150232. Based on interview and record review, the facility failed to 1.) Provide adequate supervision and assistance to prevent falls with injury for 2 (Resident #103 and Resident #101) of 3 residents; 2.) implement and revise care plan interventions to prevent falls for 2 (Resident #103 and #108) resulting in Resident #103 falling and sustaining a multicompartmental acute intracranial hemorrhage (brain bleed), Resident #101 falling and sustaining T3 and T8 (spine locations) fractures, and the potential for a fall with injury for Resident #108. Findings include: Resident #103 Review of admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 10/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #103 was moderately cognitively impaired. Review of Resident #103's Care Plan revealed, (Resident #103) is at risk for falls r/t (related to ) dementia, requires assist with ADL's (activities of daily living), skin impairment to heel with recommended cushion boots, new environment, seizure disorder, psychoactive medication use, hx (history) of falls, hx of intracranial hemorrhage, hx of alcohol abuse. (Resident #103) becomes restless while in bed, at times, attempting to stand. Date initiated: 8/14/24. Interventions: Anticipate needs. Date initiated: 8/14/24 . Bed in low position when resident is in bed. Date initiated: 9/25/24 .Call light within reach. Date initiated: 8/14/24 .Encourage Resident to remain in common areas while awake. Date initiated: 8/16/24. Encourage resident to stay out in common area until HS (night time) meds given. Date initiated: 9/25/24. Have commonly used articles within easy reach. Date initiated: 8/14/24. Keep bed at transfer height. Date initiated: 9/30/24. Low bed at all times. Date initiated: 8/14/24 .Offer resident frequent reminders to use call light during interactions. Date initiated: 8/14/24 . Offer toileting frequently throughout the day. Date initiated: 9/20/24 . Review of Resident #103's Fall Risk Evaluation dated 12/26/24 indicated that Resident #103 was confused most/all of the time, had a history of 3 or more falls within the last 3 months, was routinely incontinent, had adequate vision, was moderate/severely unsteady and required physical assistance. Resident #103 was impulsive, lacked understanding of physical and cognitive limitations and forgot or did not always use assistive devices. Resident #103 took three or more medications which increased risks for falls and Resident #103 had 3or more predisposing diseases and conditions which increased risk for falls . Review of an Incident Report submitted by Nursing Home Administrator (NHA) A dated 1/12/25 revealed, . Details: (Resident #103) was seen in the bathroom laying on his back with an abrasion on his forehead, he was able to tell staff that he didn't hit his head, but he had a change in condition and staff notified on-call physician and an order was to send to local hospital. (Resident #103) returned with a hemorrhage. A full investigation will follow . Review of Resident #103's Progress Notes dated 1/10/2025 and documented by Registered Nurse (RN) HH revealed, Patient (Resident #103) was observed laying on the floor in restroom/ bedroom. This nurse was informed by CNA (Certified Nursing Assistant) that patient fell. Patient wheelchair was in the hallway. Patient was observed in a supine position face upward. Patient was assessed for injury and vital signs obtained. Patient has abrasion noted to bil (bilateral) elbows, and abrasion noted to left knee x2. Patient was transferred from floor to bed via hoyer. Patient is denying hitting head and pain and discomfort at this time. Provider notified of this fall along with DON (Director of Nursing). This nurse attempted to reach out to patient family unable to reach. Patient was treated with schedule pain medication. Patient appears to be in no pain or discomfort at this time. Provider gave orders to dress the abrasion with xerofoam (type of sterile gauze) and cover with Mepliex (type of dressing) foam change QOD (every other day) until Monday when wound staff can follow up. Review of Resident #103's Hospital Records dated 1/12/25 revealed, . Chief Complaint: Fall Injury (Unwitnessed fall on Friday evening, did not seek medical attention at that time. Staff reports that patient is more somnolent (drowsy) since either yesterday or this morning, is normally confused but alert and conversative.) . Treatment Plan: Patient seen and examined by myself as well as my attending physician for a chief complaint of a fall on Friday for which he did not seek medical attention with increased somnolence/decreased mentation over the last 24 to 48 hours. At bedside patient Semi-Fowler's (lying on back with head of bed elevated) in bed, nontoxic-appearing, mumbling, not answering questions appropriately, not following commands. Vital signs assessed and patient was mildly hypertensive 180/100 . Physical exam findings did reveal a contusion over patient's left and right forehead with no deformity or crepitus or overlying laceration. Patient also had a significant number of bandages over all major joints with various dates from multiple falls over the last couple weeks no evidence of joint instability in extremities .Based on patient's initial presentation my initial clinical suspicion included intracranial hemorrhage from recent fall .I independently interpreted patient's head CT (computed tomography scan) and did appreciate what appears to be a significant intracerebral hemorrhage with no obvious fracture or dislocation . Given the protracted nature of time since the onset of symptoms and unsure disposition, patient's DPOA( durable power of attorney)contacted who is his eldest daughter and states the patient is currently a DNR (Do Not Resuscitate) and that she would like to discuss the case with her younger sibling to decide how to proceed whether or not to bring patient home for comfort care or if they would like patient admitted with more aggressive measures .Patient's DPOA/eldest daughter did contact me and states after discussing the case with her sister they do believe that they would like to have patient brought back to the sending facility and would be contacting hospice . Shortly after updating patient's daughter on the plan nursing alerted me that patient had fallen out of bed and landed on his face resulting in a significant laceration to the forehead and bridge of the nose. Patient was cleaned up and assisted back to bed by nursing. Given the goals of care as well as known intracranial hemorrhage no repeat imaging was performed based on goals of care wishes. Patient's lacerations were closed without complication; . It was noted that there were no care plan interventions added to Resident #103's Care Plan after his falls on 1/10/25 or 1/14/25. Review of Resident #103's Progress Not dated 1/14/25 revealed, Note Text: (Resident #103) was noted on the floor mat next to his bed by a CNA (Certified Nursing Assistant) assigned to the unit. (Resident #103) was alert and talkative upon assessment. Zero injury noted . He stated that he was trying to get himself to the bathroom because he had to urinate. This Nurse explained to him that there was a catheter in place to catch his urine . During an interview on 2/19/25 at 12:52 PM, CNA Z reported that she was the staff member that found Resident #103 on his bathroom floor after an unwitnessed fall on 1/10/25. CNA Z reported that Resident #103 was found on his bathroom floor, and that he had reported to her that he was trying to get up to go to the bathroom. CNA Z was unable to report the last time she had checked on Resident #103. CNA Z was unable to report how often staff were supposed to check on Resident #103. CNA Z confirmed that Resident #103 was supposed to be assisted to the restroom every two hours. CNA Z reported that she had no clue when Resident #103 had last been assisted to the toilet. CNA Z reported that Resident #103 would sometimes use his call light, but that he was also impulsive, and would frequently self transfer without asking for assistance. CNA Z did not know other care plan interventions that were in place to decrease Resident #103's risks for falls. During an interview on 2/18/25 at 9:10 AM, Registered Nurse (RN) HH reported that she was the staff member that assessed Resident #103 after his fall on 1/10/25. RN HH reported that she had never cared for Resident #103 before, and was not aware that he was a high fall risk. RN HH reported that she had reached out to the Director of Nursing (DON) for assistance after Resident #103's fall for assistance, and she was told that the DON would complete the incident report and create new care plan interventions to reduce Resident #103's risks for more falls. RN HH confirmed that she did not implement any immediate interventions to reduce Resident #103's risks more falls. During an interview on 2/19/25 at 11:23 AM, Licensed Practical Nurse (LPN) EE reported that Resident #103 was a fall risk. LPN EE reported that Resident #103 would frequently attempt to self-transfer. LPN EE reported that Resident #103 would occasionally use a call light, but he often would try to do things himself. LPN EE reported that the only fall prevention interventions in place for Resident #103 that she could recall were a fall mat in his room, and grippy socks. During an interview on 2/19/25 at 4:21 PM, LPN GG reported that Resident #103 was frequently restless and confused, and would often try to self transfer. LPN GG confirmed that Resident #103 had fallen frequently at the facility. LPN GG reported that she did not think that Resident #103 was on a toileting schedule, or how often staff were supposed to check on him. This writer queried what frequently was defined as for Resident #103's care plan intervention which stated Offer toileting frequently throughout the day. Date initiated: 9/20/24. LPN GG reported that she did not know what frequently was defined as, and confirmed that Resident #103's care plan intervention was not descriptive enough for staff to follow. LPN GG reported that the facility had struggled with staffing, and the unit that Resident #103 resided on required more staffing to provide adequate supervision of all of the residents, which they did not always have. During an interview on 2/20/25 at 9:42 AM, Unit Manager (UM) DD reviewed Resident #103's care plan with this writer and confirmed that Resident #103's care plan was not descriptive enough for staff to follow. During an interview on 2/19/25 at 10:56 AM, Former Assistant Director of Nursing (ADON) D reported that staffing at the facility had been a major issue, and it had affected resident care, including staff being able to provide adequate supervision. ADON D reported that the facility was wildly out of control and residents were frequently falling. ADON D confirmed that the facility did not have IDT (interdisciplinary) meetings after resident falls to review the fall and implement new care plan interventions to reduce further falls. During an interview on 2/20/25 at 10:47 AM, DON B reviewed Resident #103's care plan with this writer and confirmed that the care plan interventions were too broad and not easy for staff to follow. During an interview on 2/20/25 at 1:40 PM, Nursing Home Administrator (NHA) A reported that she was responsible for investigating Resident #103's fall on 1/10/25. NHA A was unable to report the findings from her investigation as to why Resident #103 fell, and what changes the facility made to decrease further falls. NHA A confirmed that the facility IDT team had not met after Resident #103's falls on 1/10/25 and 1/14/25 to implement new interventions to reduce further falls. NHA A reported that Resident #103 had last been assisted to the toilet around 11:00 AM, and she thought that Resident #103 had fallen around 8:00 PM. NHA A confirmed that she did not know how long it had been since Resident #103 had been checked on by staff. NHA A reported that she did not review Resident #103's hospital records from his fall on 1/10/25, and she was unaware that Resident #103 had been diagnosed with multicompartmental acute intracranial hemorrhage prior to his fall at the hospital. NHA A confirmed that Resident #103 fell on 1/14/25 after he returned from the hospital. Review of the facility's Fall Policy dated 12/13/23 revealed, Policy Overview: The purpose of this policy is to provide guidelines to

This citation pertains to intake #MI00149046 Based on interview and record review, the facility failed to implement their abuse policy and respond immediately to protect a resident from staff to resident abuse in 1 (Resident #114) of 15 residents reviewed for abuse, resulting in continued physical/verbal abuse when facility staff did not immediately identify abuse and remove the resident from contact with the alleged abuser. Findings include: Review of a Facility Reported Incident (FRI) Intake Information Report revealed, .Facility incident report received via online submission on: 11/20/24, 1:30 PM .Incident Summary Staff members (Certified Nurse Aide (CNA) M) & (CNA N) reported to (Assistant Director of Nursing (ADON) C) that (CNA UU) while washing resident (Resident #114) up, resident hit (CNA UU) in the arm. The assigned CNA (CNA UU) hit resident back .Investigation Summary Title of Incident: Resident Abuse Date/Time of Incident: 11/20/24 11:30 am .Statement of Incident: Three CNAs were providing care to (Resident #114) around 11:30 am. The assigned CNA (CNA UU) was standing to the left side of the resident. The resident reached up and grabbed at the CNAs (CNA UU) shoulders. The CNA (CNA UU) began smacking her with an open palm to (Resident #114)'s back. It was reported by the two other CNAs (CNA M & N) that (CNA UU) and (Resident #114) continued hitting each other back and forth. Per CNA (CNA UU) she grabbed the residents arm to stop her from hitting her. Per CNAs (CNA M & N), CNA (CNA UU) had pushed it down and they felt she had twisted it and continued to hit each other with an open hand. There is a discrepancy in the number of times that the resident was hit, however statements of both CNAs (CNA M & N) state that it was approximately 10-20 times Resident #114 Review of an admission Record revealed Resident #114 was a female, with pertinent diagnoses which included: cognitive communication deficit, major depressive disorder, muscle weakness (generalized). Review of a Minimum Data Set (MDS) assessment for Resident #114, with a reference date of 10/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #114 was severely cognitively impaired. Review of Resident #114's current Care Plan revealed the focus, Resident has a past potentially traumatic event related to being physical assault (being slapped multiple times) with a date initiated of 11/21/24 and care planned interventions which included, Encourage resident to talk about traumatic event at their own pace .Monitor for changes in cognition and behavior and report observation to services/nursing .Offer reassurance of safety and security with date initiated of 11/21/24. Review of a witness statement from CNA M (not dated) revealed, We were wrapping up the bed bath. Assigned CNA (CNA UU) washed up arm pits. Resident had hit assigned CNA (CNA UU) in the arm. The assigned CNA (CNA UU) hit resident with substantial force. They hit each other back and forth over 10 times. During the situation the CNA (CNA UU) said, I fight back multiple times. Resident called assigned CNA (CNA UU) an A**hole the assigned CNA (CNA UU) responded by saying, your mom is an a**hole. The area of injury is upper arm, shoulder, twisting the wrist. In an interview on 1/2/25 at 2:23 PM, CNA M discussed the details of his witness statement with this surveyor and recounted the staff-to-resident abuse event that he had witnessed on 11/20/24 at 1:30 PM. CNA M reported he had been in the room at the time of the abuse because he was there to assist with Resident #114's bed bath. This surveyor asked CNA M what, if anything, had he and the other CNA (CNA N) who were present during the abuse done to intervene and protect Resident #114. CNA M reported they had done nothing. CNA M reported he had thought if he had gotten in the middle, CNA UU might have posed a threat to him as well and stated, I honestly couldn't even think straight. I have never seen anybody actually hit a resident with substantial force before at work with an elderly patient. CNA M reported it was hard to make the right decision and by the time he had gotten himself together the incident was over. Review of a witness statement from CNA N (not dated) revealed, Around 1130-1140am, I (CNA N), (CNA M), (CNA UU) went to give a resident to give her a bed bath. I was standing at the foot of the bed and (CNA UU) was on the left side of the resident. The resident grabbed (CNA UU)'s shoulder and (CNA UU) started smacking the resident saying, I hit back and smacked the resident's hand again. The resident began crying and they started hitting each other back and forth. (CNA UU) then twisted the resident's arm. Me and (CNA M) walked out. As we were walking down the hall, I could still hear (CNA UU) and resident yelling at each other and another loud slap. I texted (ADON C) to talk and told her everything. Resident got hit at least over 20 times on her left upper side of her body and back of the head and upper back. In an interview on 1/2/25 at 3:46 PM, CNA N discussed the details of her witness statement with this surveyor and recounted the staff-to-resident abuse event that she had witnessed on 11/20/24 at 1:30 PM. CNA N reported she had been training with CNA UU that day and was told to observe CNA UU and CNA M provide Resident #114 with a bed bath. CNA N reported when CNA UU started washing Resident #114 up, Resident #114 grabbed CNA UU's clothing at which point CNA UU turned around and started slapping Resident #114. CNA N reported then CNA UU and Resident #114 started hitting each other back and forth. This surveyor asked CNA N what, if anything, had she and the other CNA (CNA M) who were present during the abuse done to intervene and protect Resident #114. CNA N reported that she and CNA M were just in shock. CNA N reported she hadn't tried to intervene because she just got stuck and was scared and didn't know what to do. CNA N reported she hadn't known if intervening would escalate things worse. In an interview on 1/3/25 at 9:30 AM, ADON C reported she had worked on the investigation of the staff-to-resident abuse between CNA UU and Resident #114. ADON C reported the expectation was that CNA M and CNA N would have stopped the abuse and protected the resident. ADON C reported CNA M and CNA N should not have left CNA UU alone in the room with Resident #114 after they had witnessed the abuse. Review of the facility Abuse Policy & Procedure last revised 4/13/23 revealed, POLICY OVERVIEW: Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property .PROTECTION: Abuse against residents can be perpetrated by various people within the facility. The facility supports and protects residents, family members, and staff from harm during an investigation of alleged abuse including retribution and retaliation. Protective actions depend upon the people involved. Any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator .The facility will make efforts to ensure all residents area protected from retaliation, physical and psychosocial harm during and after the investigation. Examples include but are not limited to: * Immediately removing the resident from contact with the alleged abuser . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included re-education to all staff on the facility policy & procedure on Abuse, on-going staff training on caregiver fatigue, re-education to staff on dealing with combative residents, and provided information and resources on staff burnout and fatigue. 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 # MI00147580, MI00149295, & MI00149428. Based on interview, and record review, the facility failed to ensure residents are free from significant medication errors in 5 of 14 residents (Resident #118, #103, #113, #124, & #125) reviewed for medication administration, resulting in a significant change in condition and hospitalization for Resident #118, and the potential for adverse effects due to missed medications. Findings include: The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition. Resident #118 Review of an admission Record revealed Resident #118 was a male, with pertinent diagnoses which included heart failure, atrial fibrillation (an irregular heart rate that results in poor blood flow), respiratory failure, kidney disease, stroke, and high blood pressure. Review of a Minimum Data Set (MDS) assessment for Resident #118, with a reference date of 12/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a Nursing - Transfer to Hospital Summary for Resident #118, dated 12/30/24 at 6:37 PM, revealed .Resident was in bed alert with prompting .Resident brother at bedside during the morning. Medications reviewed with brother .Brother was concerned resident was not staying awake during visit .VS (Vital Signs) obtained (oxygen via nasal cannula) increased to 5 (Liters) .to maintain (oxygen) above 90%. NP (Nurse Practitioner) called .brother wanted to send patient to ED (Emergency Department) . In an interview on 1/6/25 at 12:15 PM, Unit Manager LL reported they assessed Resident #118 prior to his hospitalization on 12/30/24. Unit Manager LL reported they were working on a different unit when Resident #118's nurse came to get them for a second opinion. Unit Manager LL reported Resident #118's family member had been in earlier asking about Resident #118's ordered medications. Unit Manager LL reported Resident #118's oxygen saturation had been low and the assigned nurse had increased his oxygen to keep his saturation above 90%. Unit Manager LL reported Resident #118 appeared calm and did make eye contact and respond to his name. Unit Manager LL reported Resident #118's family member was concerned, and wanted Resident #118 to be sent to the hospital since he seemed more sleepy/tired than usual. In an interview on 1/6/25 at 12:23 PM, Agency Licensed Practical Nurse (LPN) DDD reported they were the nurse assigned to Resident #118 at the time of his hospitalization on 12/30/24. Agency LPN DDD reported Resident #118 was awake but appeared to have labored breathing. Agency LPN DDD reported since they were not sure of Resident #118's baseline, they requested Unit Manager LL to assess Resident #118. Agency LPN DDD reported they checked on him several times and he would respond and make eye contact. Agency LPN DDD stated .the breathing was my concern . and reported both Resident #118's pulse and respiration rate were high. Agency LPN DDD reported Resident #118's family member was concerned that Resident #118 was not his usual self, and wanted him sent to the hospital for further evaluation. Agency LPN DDD reported Resident #118 had a PRN (as needed) medication ordered for anxiety, but no doses were administered on their shift. Review of an Emergency Department (ED) Physician Note for Resident #118, dated 12/30/24, revealed .presented from nursing facility with acute Encephalopathy, un arousable, only arousing to sternal rub .Drug screen pending .Upper and lower extremities are cold to touch .Concerned if he is in cardiogenic shock .QTC is very prolonged >600s, holding amiodarone .Avoid QT prolonging (medications) .transferred to the intensive care unit (ICU) . Review of a Hospital Physician Note for Resident #118, dated 12/31/24, revealed .Presented this admission from LTC (Long-Term Care) for change in mentation and abnormal breathing .Amiodarone started last admission .EKG upon admission demonstrated prolonged QTc. Agree with holding at this time .Per ICU notes - may be related to Trazodone use .Monitor QTc and rhythm . Review of a Hospital Physician Note for Resident #118, dated 1/1/25, revealed .Patient was brought in from his long-term care facility to emergency department with acute encephalopathy leading to worsening acute hypoxic respiratory failure. He was difficult to arouse in the emergency department so he was admitted to intensive care unit for close monitoring .suspected to be medication related: Drug screen was positive for trazodone (not on facility med (medication) list, so unclear how he received this medication), but also had been on Xanax but this did not show on drug screen . Review of a Hospital Physician Note for Resident #118, dated 1/2/25, revealed .Drug Screen .Trazodone .Facility was contacted, and there was no record of trazodone administration .there is report that the patient did receive Vistaril and Xanax on the days leading up to admission. There was no benzodiazapines identified on screens .It is felt that the altered mental status may have been related to trazodone (found) on a drug screen, there is no documentation of this ever being given at the facility . In an interview on 1/7/25 at 9:30 AM, Agency Registered Nurse (RN) BBB reported Resident #118 had a PRN medication for anxiety and recalled administering the medication to Resident #118. Agency RN BBB stated .(Resident #118) had a lot of anxiety. (He) wouldn't keep his oxygen (nasal cannula) on (and) would have episodes of rapid breathing . Agency RN BBB reported Resident #118 took all his medication via a PEG (Percutaneous Endoscopic Gastrostomy) tube (a feeding tube placed through the abdominal wall). Review of an Order Summary Report for Resident #118 revealed the physician order .Xanax Oral Tablet 0.5 MG (Alprazolam) Give 0.5 mg via G-Tube (feeding tube) every 8 hours as needed for Anxiety . with a start date of 12/19/24. Note this order was discontinued on 12/26/24. Review of an Order Summary Report for Resident #118 revealed the physician order .Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet via PEG-Tube (feeding tube) every 8 hours as needed for Anxiety . with a start date of 12/29/24. Review of a Controlled Drug Receipt/Record/Disposition Form for Resident #118 revealed one Alprazolam 0.5 MG Tablet was pulled from Resident #118's medication supply for administration on 12/19/24 at 7:00 AM, one on 12/19/24 at 7:00 PM, one on 12/28/24 at 9:00 PM, and one on 12/29/24 at 12:22 PM. Note there was no active physician order for Alprazolam 0.5 MG Tablet for Resident #118 on 12/28/24. Review of the December 2024 Medication Administration Record (MAR) for Resident #118 revealed the medication Alprazolam 0.5 MG Tablet was documented as administered only one time, on 12/29/24 at 12:22 PM. No administration documentation noted in the December 2024 MAR related to the Alprazolam 0.5 MG Tablets pulled from Resident #118's medication supply on 12/19/24 (two doses) and 12/28/24 (one dose). Review of an Order Summary Report for Resident #118 revealed the physician order .Amiodarone HCl Oral Tablet 200 MG (Amiodarone HCl) Give 1 tablet .one time a day . with a start date of 12/28/24. Review of an Order Summary Report for Resident #118 revealed no physician order for Trazodone. In an interview on 1/9/25 at 1:42 PM, Assistant Director of Nursing (ADON) C reported Resident #118 was sent to the hospital on [DATE] and a drug screen revealed trazodone (an antidepressant) in his system, which he was not prescribed. ADON C reported the drug screen also indicated no alprazolam in his system, which he did have a prescription for and per the facility medication administration records had been given two doses prior to his hospitalization. ADON C reported Resident #118 was prescribed amiodarone which cannot be taken simultaneously with trazodone, due to the potential for drug interactions. Resident #103 Review of an admission Record revealed Resident #103 was a male, with pertinent diagnoses which included stroke and a seizure disorder. Review of a current Care Plan for Resident #103 revealed the focus .The resident has a seizure disorder r/t (related to) hx (history) intracerebral hemorrhage (stroke) . with interventions which included .Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness . both initiated 8/14/24. Review of the October 2024 Medication Administration Record (MAR) for Resident #103 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .levETIRAcetam Oral Tablet 500 MG (Levetiracetam) Give 1 tablet by mouth two times a day for Seizures . Review of an article titled Missed Medicines as a Seizure Trigger, dated 2024, revealed .Missing doses of seizure medicine is the most common cause of breakthrough seizures. Missed medicines can trigger seizures in people with both well-controlled and poorly controlled epilepsy. Seizures can happen more often than normal, be more intense or develop into long seizures called status epilepticus. Status epilepticus is a medical emergency and can lead to death if the seizures aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from seizures and changes in medicine levels . Retrieved from https://www.epilepsy.com/what-is-epilepsy/seizure-triggers/missed-medicines Resident #113 Review of an admission Record revealed Resident #113 was a female, with pertinent diagnoses which included diabetes. Review of a current Care Plan for Resident #113 revealed the focus .Risk (for) adverse outcomes from potential hypoglycemic (low blood sugar) or hyperglycemic (high blood sugar) episodes (diagnosis of diabetes) . initiated 8/14/24. Review of the October 2024 Medication Administration Record (MAR) for Resident #113 revealed no documentation (missed medication) on 10/12/24 in the evening for the physician order .Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 61 unit subcutaneously one time a day for diabetes . Resident #124 Review of an admission Record revealed Resident #124 was a male, with pertinent diagnoses which included heart disease, high blood pressure, and atrial fibrillation (an irregular heart rate that results in poor blood flow). Review of a current Care Plan for Resident #124 revealed the focus .The resident is on anticoagulant therapy r/t (related to) Atrial fibrillation, history of PE (pulmonary embolism) . with interventions which included .Administer medications as ordered by physician. Monitor for side effects . both initiated 8/13/24. Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .Eliquis (an anticoagulant) Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation . Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medication) on 10/26/24 in the morning for the physician order .Eliquis Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation . Review of a Cleveland Clinic page titled Anticoagulants, last reviewed/updated 1/10/22, revealed .Anticoagulants are a family of medications that stop your blood from clotting too easily. They can break down existing clots or prevent clots from forming in the first place. These medications can help stop life-threatening conditions like strokes, heart attacks and pulmonary embolisms, all of which can happen because of blood clots . Retrieved from https://my.clevelandclinic.org/health/treatments/22288-anticoagulants Resident #125 Review of an admission Record revealed Resident #125 was a male, with pertinent diagnoses which included diabetes. Review of a current Care Plan for Resident #125 revealed the focus .The resident has Diabetes Mellitus . with interventions which included .Administer medication as ordered by the physician . both initiated 8/13/24. Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously one time a day for diabetes . Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medications) on 10/19/24 in the morning for the physician orders .NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 10 unit subcutaneously three times a day for diabetes . and .NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale three times a day for diabetes . Review of a Cleveland Clinic page titled Insulin, last reviewed/updated 1/17/24, revealed .Insulin is an essential hormone. It helps your body turn food into energy and manages your blood sugar levels. If you have diabetes, your body can't make enough insulin or can't use it properly. Your healthcare provider can prescribe manufactured insulin that you take through an injection (shot), injectable pen or pump .Insulin is a naturally occurring hormone your pancreas makes that's essential for allowing your body to use sugar (glucose) for energy. If your pancreas doesn't make enough insulin or your body doesn't use insulin properly, it leads to high blood sugar levels (hyperglycemia). This results in diabetes .There are also manufactured types of insulin that people with diabetes use to manage the condition .Regular insulin (or short-acting insulin) .They begin working about 30 to 45 minutes after injection and wear off after about five to eight hours. Regular insulin peaks about two to four hours after injection .Long-lasting insulin: It takes about an hour for this type of insulin to reach your bloodstream and start working. It peaks between three and 14 hours after injection. It lasts up to a day. Types include insulin glargine .Follow your provider's instructions carefully . Retrieved from https://my.clevelandclinic.org/health/body/22601-insulin In an interview on 1/6/25 at 3:48 PM, Licensed Practical Nurse (LPN) QQ reported the evening of 10/18/24 on the 300 Hall, no residents received scheduled medications. In an interview on 1/8/25 at 9:52 AM, Former Assistant Director of Nursing (ADON) MMM reported they were aware that multiple residents missed medications the evening of 10/18/24 and stated .we did look into that . In an interview on 1/8/25 at 10:07 AM, Agency Licensed Practical Nurse (LPN) JJJ reported they worked on the 100 Hall the evening of 10/18/24. Agency LPN JJJ reported that evening there was no nurse assigned to the 300 Hall from 6:30 PM-11:00 PM. In an interview on 1/8/25 at 11:49 AM, RN PPP reported they worked at the facility on 10/19/24 and stated .they were short on nurses that morning . RN PPP recalled going over to the 300 Hall to assist with passing morning medications. RN PPP reported there was no nurse responsible for the 300 Hall at that time. RN PPP stated .It was horrible because a lot of people did not get their medications . on 10/18/24 and 10/19/24. In an interview on 1/8/25 at 1:22 PM, with Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C, DON B reported the facility recognized an issue related to the 300 Hall and missed medications on 10/18/24. DON B reported a nurse came in late on 10/19/24 to assist with medication administration on the 300 Hall and help get everything caught up. In an interview on 1/8/25 at 3:40 PM, LPN QQ reported at shift change the evening of 10/18/24, no nurse showed up for the 300 Hall. LPN QQ reported they counted the controlled substances with the other day shift nurse and locked the keys in the medication cart before leaving the facility. LPN QQ reported they wrote a shift-to-shift report on a piece of paper and left it at the desk. LPN QQ stated .(With Agency staff) you don't know who will show up . LPN QQ reported RN LLL was on the 400 Hall that night and refused to take responsibility for the 300 hall because .it was too many people . LPN QQ reported the same thing happened on 10/26/24 on day shift, where no nurse took responsibility for the 300 Hall resulting in residents not receiving their ordered medications. LPN QQ reported residents on the 400 Hall missed medications and had no nurse the evening of 10/12/24. LPN QQ reported that night (10/12/24) the Agency nurse on the schedule arrived and refused the assignment, saying she wasn't going to put her license at risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00134978. Based on interview, and record review, the facility failed to address an acute change of condition and notify the physician of persistent pain and a decline in ADL (activity of daily living) (getting out of bed) following a fall in 1 of 3 residents (Resident #100) reviewed for quality of care, resulting in a delay in pain interventions and a delay in the diagnosis of left pubic rami (pelvic bone) fracture. Findings include: Review of an admission Record revealed Resident #100 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: osteoporosis (condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist or spine) and osteoarthritis (breakdown of joint cartilage and underlying bone). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 2/9/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #100 was cognitively impaired. Review of the Functional Status revealed that Resident #100 was totally dependent and required 2 person assistance for transfers. Review of Resident #100's Care Plan that was in place at the time of the fall on 2/18/23 .INTERVENTIONS: Give analgesic (medication to relieve pain) PRN (as needed) for pain. Resident may complain of pain, stiffness, or weakness, document complaints .Monitor/document/report to MD (medical doctor), PRN s/sx (signs and symptoms) or complications related to osteoporosis: acute fracture, compression fractures .pain, especially back pain .Date Initiated 2/28/22 . In a phone interview on 3/14/23 at 10:58 A.M., Certified Nursing Assistant-Agency (CNA-A) J reported the day of Resident #100's fall that it was a very busy day and she was in a hurry. CNA-A J reported she had hooked the hoyer sling up to the hoyer lift like she always had, but that during the transfer Resident #100 slid out of the sling and landed on the floor. CNA-A J reported that Resident #100 hit the floor hard and that Resident #100 complained of pain with the transfer back into bed and with position changes while in bed, which was a new complaint. In an interview on 3/14/23 at 12:17 P.M., LPN F reported that he was called into Resident #100's room by CNA-A K on 2/18/23 due to Resident #100 falling. LPN F reported that Resident #100 was on the floor and complained of back pain with ROM (range of motion). LPN F reported that he did not perform ROM on Resident #100's left leg due to her known chronic pain in the knee. LPN F reported that when they got her back in bed she continued to complain of pain in her middle back and had increased pain when she was rolled on her side. LPN F reported that he called the on-call person and they said to give her Tylenol (over the counter pain medication), continue to monitor and that they would see her on Monday (2 days later). LPN F reported that Resident #100 continued to have pain with any movements in bed, would verbally moan when the HOB (head of bed) was raised, would yell out during repositioning and stated, .if she wasn't touched she was fine .as long as she wasn't moving she was fine . LPN F reported that Resident #100 normally got out of bed and into her chair for all meals and stated, .we did not get her up after that .because every time we moved her she would yell in pain .we fed her in bed .she was more comfortable there . LPN F reported that he administered PRN Tylenol that day, but that her routine pain medications (Gabapentin) appeared to be controlling the pain. LPN F reported that he did not follow up with the physician later that day or the next day either, because he thought they just wanted Resident #100 monitored until they came in on Monday (2 days later) and stated, .her complaints of pain were very concerning to me .we limited her movement and kept her in bed .we were very careful with her . LPN F reported that to this day Resident #100 has not been out of her bed and stated, .we haven't even tried .we don't want her to be uncomfortable .she is still complaining of pain when they (CNA's) change her . During an observation and interview on 3/14/23 at 1:00 P.M. Resident #100 was lying in bed on her back with the HOB at approximately 30 degrees. CNA G came in to assist the resident with lunch. CNA G reported that she had to raise the HOB very slow otherwise Resident #100 would scream and stated, .I think she hurt her leg .she doesn't want to get up .but before she would get up into her chair with no problem . Resident #100 reported that she had pain in her hips and stated, .it's really bad . In an interview on 3/15/23 at 11:00 A.M., Registered Nurse (RN) O reported that she had received report at the start of shift from LPN F who indicated that Resident #100 had fallen earlier in the day, and that the physician was aware and did not want anything done at that time. RN O reported that Resident #100 was uncomfortable during during repositioning and stated, .she was grimacing and saying ouch .and that was not normal for her . RN O reported that she did not follow up with the physician, because she was told that the physician was planning to see Resident #100 in a couple days. RN O reported that she would have contacted the physician if the resident had increased pain or not able to perform ROM and stated, .I focused ROM on her legs because it was painful when she moved or twisted . In an interview on 3/15/23 at 12:32 P.M., Nurse Practitioner (NP) M reported that she had received a secure text from the facility on 2/18/22 in the afternoon and she called back but had to leave a message, and then LPN F called back shortly after that reporting that Resident #100 had fallen due to improper use of the hoyer lift, that (Resident #100) was having back pain, but that she was back in bed and comfortable. NP M reported that she gave instructions to LPN F to do neuro (neurological) checks and call us back if Resident #100 was not improving and stated, .we did not get any calls that weekend .my expectation from a skilled facility is that they know the resident and when to call . NP M reported that Doctor of Osteopathic Medicine (DO) T was scheduled to see Resident #100 on 2/20/23, and during that visit, DO T made the decision to send Resident #100 out to the hospital for evaluation. Review of On-Call Communication from NP M dated 2/18/23 revealed, Received a secure text .regarding (Resident #100) reporting that she had a fall while transferring with Hoyer lift and having back pain. 1357 (1:57 P.M.) - called and left voicemail in the number provided to call back with further concerns. 1400 (2:00 P.M.) - received a call back from (LPN F) that reported (Resident #100) slipped out of the Hoyer and was guided to the floor during transfer. Her vitals were checked and stable .she did report some pain in her mid back with any movement or palpation, but otherwise denies pain and is comfortable in bed. She has not had any pain medication provided at this time. She did not remember hitting her head. Staff was vague with a report of the fall, he will look further into this. Gave orders to provide Tylenol now and EVERY EIGHT HOURS over the weekend, perform Neuro checks every four hours, and call if there is any worsening of symptoms, change in vitals, or altered mental status .Will forward to care team for discussion and follow up on Monday. Review of Resident #100's Medication Administration Record (MAR) from February indicated in addition to regularly scheduled Gabapentin (for chronic pain syndrome), Resident #100 had an order for Acetaminophen Tablet 500mg give 2 tablets by mouth every 8 hours as needed for pain, start date 1/6/23, and had received the medication a total of 3 times following her fall on 2/18/23. Indicating administration on 2/18/23 at 2:28 P.M. for pain level of 7 out of 10, on 2/21/23 at 12:40 P.M. for a pain level of 5 out of 10, and on 2/27/23 at 6:09 P.M. for a pain level of 5 out of 10. There was also an order placed after Resident #100 returned from the hospital on 2/21/22 for Buprenorphine transdermal patch (pain medication administered through a patch placed on the skin) to be applied once weekly starting on 2/22/23. This record indicates that Resident #100 received only 2 doses of PRN pain medication after her fall and prior to returning from the hospital on 2/21/23. Review of Resident #100's MAR from February revealed, Ask Resident if they are having pain and Document two times a day for evaluation. Start Date 01/29/2023. The record indicated that Resident #100 had 0/10 pain level up until the day of the fall, except for 2/6/23 indicated 2/10 pain level. Following the fall on 2/18/23 pain levels were noted in 14 of 20 evaluations, ranging from 1-6 pain level. Review of a Facility Reported Incident (FRI) received on 2/20/22 at 11:33 P.M. revealed, .On 2/18/23, (Resident #100) had a fall which resulted in no external injury. On 2/20/23, Physician sent resident out to (hospital) due to report of pain. X-ray results showed suspected fracture of the left inferior pubic ramus (pelvic bone) . Review of Resident #100's Emergency Department Summary revealed, .Arrival Date/Time: 02/20/2023 2055 (8:55 P.M.) .The patient presents to the emergency department with concerns of left hip pain. In route she was noted to be febrile .She does not have a true fever here but slightly elevated body temperature .Given the fall with mild left-sided greater trochanteric (upper leg/hip) tenderness, x-ray left hip was obtained .Pelvic x-ray however does show a pubic rami fracture .No surgery is needed. They will reach out to her for follow-up .discharge date /Time: 02/21/2023 0116 (12:16 A.M.) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00134978. Based on observation, interview, and record review, the facility failed to safely transfer 1 of 3 residents (Resident #100) reviewed for accident hazards, resulting in Resident #100's avoidable fall and sustaining a left rami (pelvic bone) fracture. Findings include: Review of an admission Record revealed Resident #100 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: osteoporosis (condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist or spine) and osteoarthritis (degenerative joint disease). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 2/9/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #100 was cognitively impaired. Review of the Functional Status revealed that Resident #100 was totally dependent and required 2 person assistance for transfers. Review of Resident #100's Care Plan that was in place at the time of the fall on 2/18/23 .has ADL (activities of daily living) self-care deficit related to cognitive impairment, weakness/debility .Date initiated 11/12/20 .INTERVENTIONS: .TRANSFER: Dependent mechanical full body lift (hoyer) with 2 staff assist. Date Initiated: 11/12/2020. The transfer intervention was revised on 03/01/2023 and revealed, TRANSFER: Dependent mechanical hoyer lift with 2 staff assist. Recommended to use full body sling. Review of a Facility Reported Incident (FRI) received on 2/20/22 at 11:33 P.M. revealed, .On 2/18/23, (Resident #100) had a fall which resulted in no external injury. On 2/20/23, Physician sent resident out to (hospital) due to report of pain. X-ray results showed suspected fracture of the left inferior pubic ramus (hip bone) . INVESTIGATION: .No injury was identified at the time of the fall. (Licensed Practical Nurse (LPN) F) reported fall to on call provider (Nurse Practitioner (NP) M). No new orders were given. Per (NP M) (Doctor of Osteopathic Medicine (DO) U) would be notified on Monday (2/20/23). (Resident #100) was monitored post fall with Vital signs and neurological checks. No concerns were noted at the time .(Resident #100) slid out of the hoyer while she was being transferred .On 2/19/23 at 7:11am, (Registered Nurse (RN) O) noted that (Resident #100) had pain with repositioning. Resident was not able to state where exactly she hurt but said yes when asked if her lower back hurt and yes when asked if legs hurt. No swelling noted or any abnormal findings at that time. Will continue to monitor. On 2/19/23 at 1:34pm, (LPN F), .noted that she stayed in bed for the shift (7-3) .Neuro checks were WNL (within normal limits). She complained of pain during repositioning of her left knee and mid back, however, resident has history of chronic pain. Scheduled pain medication was administered and it was effective in relieving pain .On 2/20/23 around 3:58pm .physician came in to assess resident post fall and placed orders for (Resident #100) to be sent out to (emergency department) to perform x-ray due to continued discomfort in her lower back. On 2/20/23 around 11:30pm .hospital report showed that (Resident #100) had a suspected fracture of the left inferior pubic ramus .On 2/21/23 at 3:16am .(Resident #100) had returned to facility with no new orders, as the fracture just needed to heal per ER (emergency room) provider . In an interview on 3/14/23 at 5:01 P.M., Director of Nursing (DON) reported that Resident #100 fell on 2/18/23 due to staff not being knowledgeable about the use of a hoyer. DON reported that Resident #100 should have been safe to transfer in the U shaped sling or the full body sling, as long as it was hooked up right and stated, .now (Resident #100) was care planned for the full body sling just to simplify the expectations for staff . In a phone interview on 3/14/23 at 10:58 A.M., Certified Nursing Assistant-Agency (CNA-A) J reported the day of Resident #100's fall that it was a very busy day and she was in a hurry. CNA-A J reported she had hooked the hoyer sling up to the hoyer lift like she always had, but that during the transfer Resident #100 slid out of the sling and landed on the floor. CNA-A J reported that Resident #100 hit the floor hard, and that she stayed with the resident while CNA-A K left to get Licensed Practical Nurse (LPN) F. CNA-A J reported that LPN F came into the room, along with other CNA's, and we got her back into bed, and LPN F told me that I had used the wrong type of sling to do the transfer. CNA-A J reported that Resident #100 complained of pain with the transfer into bed and with position changes while in bed, which was a new complaint. CNA-A J reported that DON called her a couple days later to inform of Resident #100's injury due to the fall and requested that CNA-A J come in to the facility to further discuss the incident. CNA-A J reported that she and CNA-A K reenacted that scenario for DON to observe, were briefly educated, and it was determined that CNA-A J had hooked the hoyer sling up wrong. CNA-A J reported that she was told that she was supposed to criss-crossed the leg straps prior to hooking the sling onto the hoyer lift and stated, .I had no idea .I always did it that way .no one had ever corrected me .I didn't even know she was supposed to have a full body sling .I am still confused to this day . CNA-A J reported that the sheet of paper that the facility had given her only indicated that Resident #100 used the hoyer lift, but did not specify a specific sling and stated, .I had never used the type of hoyer that the facility had until I worked there .as an agency CNA you have to figure it our for yourself .I don't know how to look at the care plan .I didn't know anything about her .it was very unorganized . CNA-A J reported that she had only worked in the facility 2 or 3 shifts, because she had called off several times and stated, .after that I canceled all my shifts .I was not comfortable working there . In a phone interview on 3/14/23 at 11:24 A.M., CNA-A K reported that she assisted CNA-A J with Resident #100's hoyer transfer on 2/18/23. CNA-A K reported that when Resident #100 was lifted up, she slipped right out of the sling and fell on the floor, landing on her bottom and stated, .(CNA-A J) didn't cross the leg straps .I didn't notice until (Resident #100) started sliding out of the sling .it happened so fast . CNA-A K reported that it was her one and only time working at the facility and stated, .I did not get any training .no help with anything .no welcoming or nothing .no one even showed me around .I had to figure things out myself . In an interview on 3/14/23 at 12:17 P.M., LPN F reported that the day that Resident #100 fell there were 2 agency CNA's working on the hall and stated, .I was told that one of them had been here twice . LPN F reported that he was called into Resident #100's room by CNA-A K. LPN F reported that Resident #100 was on the floor and complained of back pain with ROM (range of motion). LPN F reported that he did not perform ROM on Resident #100's left leg due to her known chronic pain in the knee. LPN F reported that when they got her back in bed she continued to complain of pain in her middle back and had increased pain when she was rolled on her side. LPN F reported that he called the on-call person and they said to give her Tylenol, continue to monitor and that they would see her on Monday (2 days later). LPN F reported that there are a lot of agency CNA's working in the facility and they do not know the residents, and that he educated the agency CNA's involved afterwards about using a full body hoyer pad for Resident #100 due to her weight and her body being limp. LPN F reported that he reminded the agency CNA's to check the resident's [NAME] (direct care-givers care guide) prior to providing care, and that CNA-A J told him that she had checked the [NAME] and that it did not indicate the type of hoyer sling that the resident required. During an observation and interview on 3/14/23 at 1:00 P.M. Resident #100 was lying in bed on her back with the HOB at approximately 30 degrees. CNA G came in to assist the resident with lunch. CNA G reported that she had to raise the HOB very slow otherwise Resident #100 will scream and stated, .I think she hurt her leg .she doesn't want to get up .but before she would get up into her chair with no problem . Resident #100 reported that she had pain in her hips and stated, .it's really bad . In an interview on 3/14/23 at 3:32 P.M., CNA Q reported that Resident #100 used to get up in her chair everyday and now she is in bed all of the time. In an interview on 3/15/23 at 12:32 P.M., Nurse Practitioner (NP) M reported that she had received a secure text from the facility on 2/18/22 in the afternoon and she called back but had to leave a message, and then LPN F called back shortly after that, reporting that Resident #100 had fallen due to improper use of the hoyer lift, that she was having back pain, but that she was back in bed and comfortable. NP M reported that she gave instructions to LPN F to do every 2 hours neuro (neurological) checks and call us back if Resident #100 was not improving and stated, .we did not get any calls .my expectation from a skilled facility is that they know the resident and when to call . NP M reported that Doctor of Osteopathic Medicine (DO) T was scheduled to see Resident #100 on 2/20/23, and DO T made the decision at that time to send Resident #100 out to the hospital for evaluation due to the amount of pain she was having. Review of On-Call Communication from NP M dated 2/18/23 revealed, Received a secure text .regarding (Resident #100) reporting that she had a fall while transferring with Hoyer lift and having back pain. 1357 (1:57 P.M.) - called and left voicemail in the number provided to call back with further concerns. 1400 (2:00 P.M.) - received a call back from (LPN F) that reported (Resident #100) slipped out of the Hoyer and was guided to the floor during transfer. Her vitals were checked and stable .she did report some pain in her mid back with any movement or palpation, but otherwise denies pain and is comfortable in bed. She has not had any pain medication provided at this time. She did not remember hitting her head. Staff was vague with a report of the fall, he (LPN F)will look further into this. Gave orders to provide Tylenol now and every eight hours over the weekend, perform Neuro checks every four hours, and call if there is any worsening of symptoms, change in vitals, or altered mental status .Will forward to care team for discussion and follow up on Monday. Review of Resident #100's Medication Administration Record (MAR) from February indicated in addition to regularly scheduled Gabapentin (for chronic pain syndrome), Resident #100 had an order for Acetaminophen Tablet 500mg give 2 tablets by mouth every 8 hours as needed for pain, start date 1/6/23, and received the medication a total of 3 times following her fall on 2/18/23. Indicating administration on 2/18/23 at 2:28 P.M. for pain level of 7 out of 10, on 2/21/23 at 12:40 P.M. for a pain level of 5 out of 10, and on 2/27/23 at 6:09 P.M. for a pain level of 5 out of 10. Also Buprenorphine transdermal patch (pain medication administered through a patch placed on the skin) applied once weekly starting on 2/22/23. This record indicates that Resident #100 received only 2 doses of pain medication after her fall and prior to returning from the hospital on 2/21/23. Review of Resident #100's MAR from February revealed, Ask Resident if they are having pain and Document two times a day for evaluation. Start Date 01/29/2023. And indicated that Resident #100 had 0/10 pain level up until the day of the fall, except for 2/6/23 indicated 2/10 pain level. Following the fall on 2/18/23 pain levels were noted in 14 of 20 evaluations, ranging from 1-6 pain level. Review of Resident #100's Emergency Department Summary dated 2/21/22 revealed, .Arrival Date/Time: 02/20/2023 2055 (8:55 P.M.) .The patient presents to the emergency department with concerns of left hip pain. In route she was noted to be febrile .She does not have a true fever here but slightly elevated body temperature .Given the fall with mild left-sided greater trochanteric (upper leg/hip) tenderness, x-ray left hip was obtained .Pelvic x-ray however does show a pubic rami fracture (pelvic bone) .No surgery is needed. They will reach out to her for follow-up .discharge date /Time: 02/21/2023 0116 (12:16 A.M.) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 Review of a Face Sheet revealed Resident #28 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia; hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side; pressure ulcer of unspecified buttock, Stage 3; unspecified abnormalities of gait (walking) and mobility. Review of a Minimum Data Set (MDS) assessment for Resident #28, with a reference date of 12/22/22 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #28 was cognitively impaired. Review of Resident #28's assessed Functional Status of said MDS revealed Resident #28 required extensive, 1-person physical assist with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed); extensive, 2-person physical assist with transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position); and extensive, 1-person physical assist with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor). Review of Resident #28's current Care Plan revealed a focus of (Resident #28) has a stage 3 pressure ulcer on his left buttock with care planned interventions which included Assist with turning and repositioning on or about every two hours and prn (as needed) with a date initiated of 12/21/22. In an interview on 2/15/23 at 10:59 AM, Certified Nurse Aide (CNA) X reported has cared for Resident #28 and knew he had a pressure ulcer on his bottom. CNA X was queried regarding when Resident #28 should be repositioned according to his current Care Plan. CNA X reported did not think Resident #28 was on the list to be repositioned and that he preferred to be in his wheelchair. CNA X reported staff was supposed to walk with Resident #28 to meals and that was considered his repositioning/offloading (take the weight off/relieve pressure from affected area). CNA X reported Resident #28 did not always get walked to meals because needed two staff to assist him and there were not always 2 staff available to do so. In an interview on 2/15/23 at 2:24 PM, Director of Nursing (DON) B reported if a resident was supposed to be walked to meals, it would be documented in the Electronic Medical Record under the Task when the task was completed or if the resident refused. Review of a Task report detailing Resident #28's Task: Walk to dine with walker, gait belt and 1 assist Look Back: 30 days (1/17/23-2/15/23) .Question 2 .Support Provided revealed: out of 90 walk to dine opportunities (3 meals per day for 30 day look back), there was 1 entry that Resident #28 refused, 27 entries of response not required, and 32 entries indicating Resident #28 had received either 1-person or 2-person assistance to walk to dine. Based on observation, interview and record review the facility failed to ensure residents consistently received treatment and services to prevent the worsening of a pressure ulcers for 3 residents (Resident #79, #39 and #28) of 3 residents reviewed for pressure ulcers, resulting in the worsening of a Stage 3 pressure ulcer for Resident #79 and a potential for worsening of facility acquired pressure ulcers for Resident #39 and #28. Findings include: Resident #79 Review of an admission Record revealed Resident #79 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcer of sacral (tail bone) region, Stage 3. Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 12/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #79 was cognitively intact. Review of the Functional Status revealed that Resident #79 required extensive assistance of 2 staff members for positioning in bed, and was completely dependent on 2 staff members for toileting. During an observation and interview on 02/13/23 at 09:26 A.M. Resident #79 was lying in bed on his back with his legs propped up on a wedge and the HOB (head of bed) at approximately 30 degrees. Resident #79 reported that he put his call light on 45 minutes ago because he had not received his breakfast and stated, .it should have been here an hour ago .I just eat cereal because the other food is always cold .I don't complain, I just won't eat it .eggs are like ice .buttered toast has been sitting too long . Resident #79 reported that his room was at the end of the hall and that if he ate in the dining room the food was better. At 09:48 A.M. Resident #79 reported that he does not get out of bed and was incontinent of bowel and bladder and that the incontinence was the reason that he had a urinary catheter. Resident #79's catheter drainage bag was observed at the bedside. Resident #79's visitor exited Resident #79's room and collected his breakfast tray from the meal cart on the hall, and then turned the call light off. Review of Resident #79's Care Plan revealed, .FOCUS: stage 3 pressure ulcer on his coccyx. Date initiated 9/19/22 .INTERVENTIONS: .Assist with bed mobility/turning and repositioning on or about every 2 hours and PRN (as needed) .FOCUS: Foley Catheter (tube inserted into penis to drain urine from the body) for the treatment of sacral wound .FOCUS: .at risk for impaired skin integrity r/t (related to) diabetes mellitus, malignant neoplasm (cancer) prostate, impaired mobility, current pressure ulcer. Date initiated 9/19/22. There was no record of Resident #79 being incontinent or interventions related to incontinence care. During an observation and interview on 02/15/23 at 08:42 A.M. Resident #79 was lying in bed on his back and his breakfast tray was observed untouched. Certified Nursing Assistant (CNA) BB picked up the breakfast tray, but did not provide cares for Resident #79. Resident #79 reported that he had a bedsore on his bottom that was painful to touch. During an observation of wound care for Resident #79 on 02/15/23 at 09:46 A.M. Physician Assistant (PA) F, Registered Dietician (RD) JJ and Nurse Supervisor (NS) L entered the residents room with supplies to complete wound care, and Resident #79 was observed lying on his back in bed. Resident #79 was turned onto his right side, revealing his incontinence brief that was completely saturated with urine. The brief was removed and Resident #79 had also had a BM (bowel movement). NS L reported that Resident #79's urine catheter must have been leaking. A tan colored bandage, approximately 3 x 3 inches was observed on the sacral area, partially detached and wet with urine. After the bandage was removed the wound was observed with approximately 1 inch of open wound with bright red active bleeding, and the surrounding skin was lighter in color and wrinkly (macerated: occurs when skin is in contact with moisture for too long). NS L was holding pressure to the wound with guauze. PA F reported the wound measurement was 1.8 cm x 0.7 cm x 0.3 cm and stated, .the surface area has slightly increased. Resident #79 reported that the last time his brief was changed was last night and that he was not able to feel when he was wet or if he had a BM. Resident #79 reported that when staff ask him if he needs his brief changed and he tells them that he is ok. NS L applied topical medihoney (assists in wound healing), a sheet of Silver Alginate (antibacterial), and a large padded bandage to cover the entire sacral area. In an interview on 02/15/23 at 10:09 A.M., PA L reported that being wet and soiled can negatively effect Resident #79's wound healing progress and that due to Resident #79's inability to recognize when he urinates or has a BM, incontinence care should be provided every 2 hours. In an interview on 02/15/23 at 10:12 A.M., CNA BB reported that Resident #79 was her responsibility and that she had not checked Resident #79's brief yet that day. CNA BB reported that 3rd shift CNA T had reported that Resident #79 was done during shift change report at 6:30 A.M. that morning. CNA BB then reported that she had gotten caught up passing breakfast trays this morning and could not leave the meal cart until all the trays were served, and that was the reason she had not checked Resident #79's brief. This surveyor attempted to contact CNA T by phone on 02/15/23 at 11:22 A.M., but no return call was received. Review of Resident #79's Wound Visit dated 2/15/23 revealed, .sacrum .Present on admission .Pressure .Wound Assessment: .Stage 3 Pressure Injury Pressure ulcer .not healed .measurements are 1.8 cm length x 0.7 cm width x 0.3 cm depth .moderate amount of serous (clear) drainage noted .The periwound (surrounding area) skin exhibited: Denuded (loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate (drainage) or friction) .SA (surface area) Slightly increased .Wound goals: healing . Review of Resident #79's Wound Visit Note dated 2/9/23 revealed, .sacrum .Present on admission .Pressure .Wound Assessment: .Stage 3 Pressure Injury Pressure ulcer .not healed .measurements are 1.5 cm length x 0.6 cm width x 0.3 cm depth .Wound goals: healing . Resident #39 Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 1/24/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #39 was cognitively intact. Review of the Functional Status revealed that Resident #39 required extensive assistance of 1 staff member for positioning in bed, and extensive assistance on 2 staff members for toileting. Review of Resident #39's Care Plan revealed, .at risk for pressure injuries, related to weakness/debility, impaired mobility, in bed or chair all day .h/o (history of) pressure injuries. Date initiated: 7/15/2020 . Interventions: .heels up, pillows, offloading, boots . Reposition or cue to reposition on or about Q2 hours (every two hours). Date initiated: 7/15/2020 .(Resident #39) has actual impairment to skin integrity, r/t (related to) edema, fragile skin, and leaning to his right. He has an unstageable pressure ulcer on his left heel. Date initiated: 4/20/2020. Interventions: . encourage to elevate his legs when sitting . During an observation and interview on 02/13/23 at 10:00 A.M. Resident #39 was lying in bed on his back with the HOB at approximately 90 degrees. Resident #39 was slouched down in bed and his legs were bent and both feet were pressed firmly against the footboard of the bed. Resident #39 had a blue pressure reducing boot on his left foot. Resident #39 reported that he had a deep sore on the bottom of his left foot and stated, .yeah it hurts .I am actually pushing my foot against the end of the bed .I am slouched down too far .they don't want me to move around by myself . During an observation on 02/14/23 at 08:53 A.M. Resident #39 was lying in bed on his back with the HOB at approximately 90 degrees. Resident #39 was position like the day before, slouched down in bed and his legs were bent and both feet were pressed firmly against the footboard of the bed. Resident #39 reported that he was uncomfortable. During an observation and interview on 02/15/23 at 09:25 A.M. of Resident #39's wound care to his left foot, NS L removed the dressing, revealing an open wound that measured 1.8 cm x 2.1 cm x 0.1 cm and NS L reported that it had improved. NP F reported that it was a pressure wound that presented as a large blister. NS L and NP F reported unsure of what caused the pressure. In an interview on 02/15/23 at 01:36 P.M. ADON reported that when Resident #39's pressure wound on his left foot was first discovered, he was sleeping in his recliner all the time and when he was ambulating in his wheelchair his foot would drag. Review of Resident #39's Wound Visit Note dated 2/15/23 revealed, .HPI (history of present illness) Left heel .Date of onset: April 2022 .Pressure .developed a blood filled blister to the left heel that has evolved .Wound Assessment: left heal Stage 3 Pressure Injury Pressure Ulcer .not healed .measurements are 1.8 cm length x 2.1 cm width x 0.1 cm depth .there is a moderate amount of sero-sanguineous (bloody) drainage noted .Pressure relief/Offloading: .float heels while in bed .offload heels .bed extender in place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to prevent falls for 1 (Resident #336) of 4 Residents reviewed for falls, resulting in a fall with fracture. Findings include: A review of a Face Sheet revealed Resident #336 was admitted on [DATE] with pertinent diagnoses that included: Dementia, Anxiety Disorder, Urinary Tract Infection (infection in the urinary system characterized by frequent urination and potential for increased confusion in the elderly), Weakness, Seizure Disorder, and Osteoporosis (medical condition resulting in brittle bones). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #336 required partial assistance (helper provides less than half the effort) to transfer from the bed to a chair and supervising or touching assistance to safely ambulate up to 50 feet. A review of a Physical Therapy Evaluation dated 1/31/23 with Resident #336's medical complexities listed as: poor historian, dementia, depression, frequent falls, unsteadiness on feet. Physical Therapy Evaluation identified the following fall predictors: delayed anticipatory reactions, impulsive ambulation, high attentional demands/conditions and unable to apply learned skills to difficult situations. Physical therapy assessment summary indicated Resident #336 had limited cognitive awareness to lock and unlock assisted device and decreased reactive balance. Review of a Fall Risk Evaluation dated 1/30/23 revealed Resident #336 had intermittent confusion,1-2 falls in the past 3 months, a balance problem while walking, required an assistive device to ambulate, was prescribed 1-2 medications known to increase fall risk and had 3 or more medication changes in the last 5 days. Resident #336's total score on this assessment was 18, indicating the Resident was at risk for falling. A review of a Care Plan dated 1/31/23 revealed the focus/goal/interventions as follows: (Resident #336) is at risk for falls related to deconditioning, gait and balance problems, Goal: The Resident will not sustain serious injury. Interventions included: Anticipate and meet resident needs, be sure Resident's call light is within reach and encourage use . educate Resident what to do if fall occurs . In an interview on 2/14/23 at 2:15pm, Certified Nursing Assistant (CENA) DD reported she arrived for work in the memory care unit at 6:30am on 2/2/23, received a little report from the night staff which did not include anything about Resident #336 other than all Resident needs were met at 5:00 am. During her initial rounding, CENA DD reported she found Resident #336 sitting on the floor in her room, leaning against the bed, and facing the head of the bed at approximately 6:50am. CENA DD indicated it appeared Resident #336 had taken self to the restroom and fell as she returned to bed. CENA DD reported there was no fall mat or position change alarm in place and Resident #336's call light had not been activated when the Resident was found on the floor. In an interview on 2/14/23 at 2:02pm, Licensed Practical Nurse (LPN) P reported she assessed Resident #336 as she (Resident #336) was on the floor. LPN P noted symptoms of a potential fracture and the staff lifted Resident #336 into bed. LPN P indicated she did not know Resident #336 well but was aware that Resident #336 was admitted to the memory care unit due to cognitive deficits. LPN P reported the physician ordered a stat Xray. Review of a Radiology Report dated 2/2/23 for Resident #336, contained results: There is a right acetabular fracture (break in the socket portion of the ball and socket hip joint) which appears to involve both the anterior and posterior columns (front and back of the bone or area around the bony rim). A review of an Emergency Department Provider Note dated 2/2/23 revealed Resident #336 was diagnosed with: Markedly comminuted fractures of the right acetabulum and right superior and inferior pubic rami with medial protrusion of the right proximal femur through the acetabular wall and a focal defect within the superolateral femoral head secondary to an acetabular bone fragment. There is significant surrounding hematoma involving the retroperitoneum, iliacus muscle, and surrounding proximal thigh muscles. The note indicated Resident #336 required critical care at this time due to the severity of the injuries. A review of a Fall Investigation document for Resident #336's fall on 2/2/23 revealed Resident #336 was admitted to the facility with bruising from recent falls and was documented as confused, disoriented and with short term memory loss. Staff reported Resident #336 got up out of bed multiple times throughout the night, at one point was taken to the dining area but then returned to bed where she only stayed for a few minutes. Resident #336 voiced multiple needs during the night, including a need to use the restroom, feeling sick and at times calling out, help me. In an interview on 2/15/23 at 3:46 p.m., CNA W reported Resident #336 would not sleep on the night of 2/1/23-2/2/23. CNA W reported that Resident #336 kept getting up independently without her walker. CNA W stated, I had to hold her up to her walker for her to use it. I told the nurse that she kept getting up and down and wouldn't stay in her bed or wheelchair, but I didn't get any further instructions on how to keep her safe. The nurse told me it had been a problem on the previous shift too. As soon as I would walk out of the room, she'd get right back up and be right behind me as I walked out of the room door. I didn't know anything about her, the resident was new. I did was I could. CNA W reported she tried to check on her more frequently, but the resident also would not use her call light consistently to let her know when she needed something. CNA W reported it was only her and a nurse on duty that night in the memory care unit and she had 11-12 residents who needed care. CNA W stated, I just couldn't be everywhere I needed to be at one time. I had to care for the other residents and (Resident #336) needed more time and attention than I could give.