**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI0014870. Based on interview and record review, the facility failed to prevent significant medication errors for 2 (R102 and R105) of 3 residents reviewed for medication errors, resulting in a change in condition, emergent transfer, and hospitalization for R102 and the potential for change in condition for R105. Findings include: According to R102's medical records diagnoses included multiple sclerosis (MS) (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord), and epilepsy (seizure). According to Seizures and multiple sclerosis more than an epidemiological association (Review) - PMC (nih.gov), Multiple sclerosis (MS), the most common inflammatory pathology of the central nervous system (CNS) . MS is associated with significant comorbidities .neurological disorders such as epilepsy, have a higher prevalence in patients with MS . Review of R102's Order Summary [DATE], reported: - Levetiracetam (Keppra)oral tablet 1000 mg, give 2 tablets by mouth 2 times a day (BID) related to epilepsy -Clobazam oral tablet 10 mg, give 1 tablet by mouth at bedtime (HS) related to epilepsy -Glatiramer Acetate subcutaneous (under the skin) solution prefilled syringe 20mg/ml. Inject 1 ml subcutaneously one time a day related to Multiple Sclerosis . epilepsy. Review of R102's Medication Administration Record (MAR), dated [DATE]-[DATE], reported the resident did not decline/miss any doses of Clobazam, or Levetiracetam. However, she was documented as refusing a dose of Glatiramer on [DATE]. Review of R102's MAR, dated [DATE]-[DATE], reported the resident did not decline/miss any doses of Clobazam, or Levetiracetam. However, she was documented as refusing a dose of Glatiramer on [DATE] and [DATE]. It was noted both on the January and February 2024 MAR the same nurse documented the medication refusal for Glatiramer with no other medications, all by mouth, refused. Review of R102's Care Plan revision [DATE], reported a focus on ADL (activities of daily living) deficit related MS and seizure disorder, with refusing at times care, medication, and meals. The goal was to actively participate in activities using interventions that included reapproaching with refusals. Review of R102's Progress Note [DATE] 10:15 (AM) reported speaking with the resident's daughter who had concerns about her mother's medication. Review of R102's Progress Note [DATE] 12:53 (PM) reported the resident was having multiple seizures that morning and one the night before. The on-call physician had been notified and gave the okay to send to the ED (emergency room). Daughters were notified at this time. Review of R102's Progress Note [DATE] 19:12 (7:12 PM), reported a daughter came into the facility and picked up 5 Glatiramer Acetate injections as hospital is unable to get them. Review of R102's Progress Note [DATE] 13:15 (1:15 PM), reported a daughter returned 5 vials of medication. Review of a Concern/Grievance Form for R102 reported the date of concern occurred on [DATE]. The person receiving the concern was NHA A on [DATE]. R102's daughters came to the facility to discuss with NHA A possible missed medication administration and lack of communication from the facility. An investigation/review/and action taken reported the facility was only able to confirm documented missed doses of any medications. The facility shared with the family members R102 only refused her Glatiramer injections once in February (2024). It was noted there was no mention of the two missed doses in January (2024). Review of R102's Emergency Department (ED) to Hospital admission notes, dated: -[DATE], reported the ED physician described the resident as disoriented and was concerned for intracranial (brain) process given the recurrent seizures. Diagnosis at time of hospital admission was 1. Seizures 2. Subdural hemorrhage (bleeding in the brain) possibly related to seizure activity; no trauma suspected. Keppra (antiseizure medication) level was below therapeutic level at 2.5. EMS reported the nursing facility noted 12 seizures in total since morning ([DATE]). EMS was informed by the facility R102 no reported missed dose of her seizure medications. EMS noted 3 seizures enroute with right-sided tonic-clonic movement with altered mental status (AMS). Reportedly R102 had no missed doses of medications however, Keppra dose was low on labs drawn in the ER (<2.5). She was admitted for further medical management. -Updated note [DATE]: Keppra level undetectable on admission which is likely cause of break through seizures .She is now residing in a facility that administers her medications so unclear why she would not be receiving Keppra . -Patient's seizure secondary to noncompliance to medications .It was noted there was no documented refusals of Keppra in R102's MAR for January and February 2024. During an interview on [DATE] at 2:15 PM, Family Member (FM) D stated, My mother (R102) has taken Glatiramer shots daily for 20 years for MS. She has seizures because of the MS. Before my mother was fully admitted to the facility, we were told by (Director of Nursing (DON) B) the facility would not pay for it, that me or my sister (co-guardians) would have to get the medication from a pharmacy and bring it to the facility. Glatiramer comes to a special pharmacy in a cooler, and I take it to the facility. It must be kept in the refrigerator. (Licensed Practical Nurse (LPN) I) called me at 8:30 AM on [DATE], telling me my mother was having seizures that started during the night. I asked why my mother was having seizures. (LPN I) said when she left on Wednesday ([DATE]) the same number of Glatiramer shots were in the refrigerator when she came back after a day or two off along with a full box. Each box holds 30 shots. The medications have lot numbers that I keep track of. The facility never asked for any paperwork for lot# or quantity. (LPN I) told me there had been 4 shots from the previous lot number plus another full box. Each box has 30 shots. She told me she had broken a syringe and had to use another one so there were 2 left of lot #4 and a full box of lot #5 on [DATE]. So that would be 32 shots on [DATE]. Fifteen minutes after (LPN I) first called me 15 minutes later she called me back and said the facility was not able to stop the seizures and was sending my mother to the hospital. EMS (Emergency Medical Services) came to the facility to get our mother. My mother was admitted to the ER (Emergency Room/Hospital) at 9:45 AM. I talked directly to the intake nurse at the hospital who told me the facility shared with EMS they witnessed 12 seizures. Then EMS witnessed 3 seizures during transport. I went to the facility the day or so and took 5 of the Glatiramer shots from the full box lot #5 up to the hospital because I did not know if they would have them. The hospital said they already had them, so I took them back to the facility. I had a conversation then with (Nursing Home Administrator (NHA) A and the Assistant Director of Nursing (ADON) who said she put them in the refrigerator. They told me my mother was refusing her medications. No one told me she was refusing. No one at the facility told me she was not getting her medication. The only time my mom has had seizures like this before. She had seizures on [DATE] but not 12. The only time a seizure would be provoked if she did not get her medications. My mother was at the hospital from [DATE] until [DATE]. The hospital found a brain bleed during testing and was then admitted . The staff there talked to my sister about her seizures and said there was an advancement with her MS. My overall frustration with the facility lies with lack of their communication. Every time my mom has a seizure it puts her 10 steps back. Her last seizure was on her birthday last year. Her husband had recently died, and she was pretty upset. But she did not have multiple seizures. The facility was so complacent with thinking a sorry would help. There are other people's parents in the facility. We are putting our trust in people to take care of our parent. It was clearly my mother was not getting her medication for months. To know there was a whole month plus longer of shots that my mom went without is scary. That box with lot #5 should have been used. The facility never gave me a receipt when I delivered the medications. Lot #4 was for the month of January. I had just recently gone to the facility for a care conference on [DATE]. They said she was stable at that time. I state, lot #4 and lot #5 because when I get the boxes, they had printed on them Lot # A 080004 had 4 as the last number. It was dated for [DATE] with a quantity of 30 shots. The next shipment was to be for [DATE]. On [DATE] she would have had a week of shots left over but she had 30 left over. My mother was not cared for like she was supposed to be. They caused my mother harm and caused her to have multiple seizures. During an interview on [DATE] at 10:00 AM, Pharmacist K stated MS is a degenerative disease of the myelin sheath (insulating layer, or sheath that forms around nerves, including those in the brain and spinal cord) around nerves which causes the body to attack the nerves as a foreign body. Glatiramer acts like a substitute insulator/replacement around the nerves, so the body is less likely to attack the nerves. The medication is an amino acid that replaces sheaths of the nerves and alters the antigen. It is possible the medication could help the body not to have seizures. Not getting the Glatiramer will cause the gradual degeneralization of the nerve sheath. Not getting medication is not ideal. During an interview and record review on [DATE] at 1:32 PM, Corporate Clinical Consultant (CCC) L, NHA A, ADON M and Director of Nursing (DON) B reviewed R102's medical chart with DON B stating, (R102) had medication refusals on [DATE], [DATE], and February 2 (2024) all by the same nurse. When a nurse documents DD in the MAR/TAR, is means the medication was declined and that auto-populates a progress note that states the resident declined the medication. I do not see any other medications were declined that day. I am not familiar with (R102) giving any reason for refusing. When (R102) first came to the facility, the facility could not get the medication (Glatiramer) through our pharmacy or the specialized pharmacy, so the family supplied it. The family brought the medication in on 200 hall where the resident lived. It had to refrigerated. The facility let (Family Member (FM) D) take 5 syringes of the medication on [DATE] and then she returned them on [DATE]. I investigated the reason 1-box of 30 syringes and 4-syringes were left. There was a total of 25 medication syringes left with no explanation why. There was an issue of why the medications were left over. It appeared typically (LPN I) was on when new boxes came in. The boxes were not dated when they came in, but there were always a few syringes left and 1 new box. Documentation does not show of any other medication refusals only the three we already talked about. The on-coming nurse said (R102) had a seizure, one, during the night from the information she got from the night (NOC) nurse. (LPN I) was the on-coming, she documented (R102) had multiple seizures that morning per her progress note. She called the on-call physician with the okay to send to the ER. DON B reviewed the progress notes and physician orders to verify. ADON M reviewed the order stating, The order to send (R102) to the ER was not put in medical records until [DATE]. Further review of R102's medical records with NHA A, CCC L, ADON M and DON B, DON B stated, (LPN) J was the NOC nurse on [DATE] assigned to (R102). She did not document in (R102) medical records about the seizure. Nor did she contact the guardians. If it is in the middle of the night and unless it was a Grand Mal seizure, I would not call and wake up the family and would wait and tell them in the morning. (R102) did not have frequent seizures. NHA A stated, The daughters came in the Monday after. 2/12 (2024) and expressed their number #1 concern was communication to call (FM E) first, then call (FM D). DON B stated, There was no documented missed doses of her Keppra or Topamax (anti-seizure medications) in January or February (2024). Policy states we do not have to notify the physician unless the refusal is two consecutive days. During an interview on [DATE] at 2:40 PM, LPN I stated, I work at the facility and took care of (R102). The family would bring in the Glatiramer syringes about every month or two. I would write on the box to contact family when getting low. I never dated or numbered the box when it came in. The family's pharmacy would label it with her name. When I got report on 2/10 (2024) from the NOC nurse, I was told she had a seizure during the night. Around 7:15-7:30 AM an aide told me she was having a seizure, it was more a focal seizure (nerve cells in the brain send out sudden, excessive, uncontrolled electrical signals). She had more seizures, probably a good handful, maybe five. The aides told me she would start shaking. She would tell me to call her daughters. I called the on-call doctor and was told to continue to monitor her. (R102) continued to have seizures so I messaged the doctor and sent her to ER. I did not put the order in. I forget to do that. I called the family after she had the first or second seizure for me. They were surprised she had a seizure because they were not called during the night. They were pretty upset she had seizures. They were upset because she had not had a seizure in a long time. I cannot assume a nurse did not give a medication and document they did. However, I am aware of a nurse, (LPN N) not giving medications. I brought it up to the Unit Manager (UM O), that other residents complain (LPN N) does not give medications and documents she does. If a resident refuses medication, the nurse is to document the reason why. After two refusals in a row, the doctor is to be called. The computer generates a progress note of refusal. I told (NHA A) and (DON B) during the time of (R102's) incident about (LPN N). I showed the DON the card stock that 2 days prior to [DATE], another nurse, (UM O) signed she administered medications that were not in the facility. It was (R105's) methocarbamol that was the card stock. Another resident told me she was not getting medications from (LPN N) and I told (UM O) within the last few months. I was not asked to, nor did I fill out any forms or statements for any of this. R105 Review of R105's medical records revealed the resident had a diagnosis of rheumatoid arthritis. Review of R105's Order Summary reported [DATE], Methocarbamol ((Robaxin) muscle spasms/pain) oral tablet 500 mg give 1 table BID. Review of R105's MAR, [DATE]-[DATE] reported Methocarbamol was documented as OS (out-of-stock) on consecutive days and scheduled times 2/3 and 2/4 (2024), was given on both scheduled times on 2/5, then documented as OS on consecutive days and scheduled times 2/6 and 2/7 (2024). A telephone call was placed on [DATE] at 3:13 PM to LPN N with no answer and a message was left to call surveyor back. No return call was made by end of survey, [DATE] at 5:30 PM. During an interview on [DATE] at 3:17 PM, LPN P stated, If a resident refuses a note is made in the eMAR (electronic medical record system). DD means a resident declined medication and a progress note is auto-populated. I typically let the physician know verbally in the unit each morning. They have a red communication folder the nurse the can write a note in there. I do not know if all the nurses use it. I received an education in the last month about calling guardians when a resident refuses medication. I regularly cared for R102, and she did not like taking the shot medication. I could [NAME] with her with ice cream or snacks. She had refused meds from me a few times. I am very thorough in my documentation. I recall the January and February 2024 refusals of the injection. I let the MAR document in the progress note of the refusal. I do not remember if I reapproached the resident. She told me around Christmas time she did not like being poked. I do not know if I documented that. I noticed just prior before she (R102) left the facility, (LPN N was hired and was put on the 200 hall with (R102). That was the time I noticed more of the Glatiramer syringes were left than should have been. There were never more than 2 boxes in the refrigerator. (LPN I) and I noticed there were more than normal. I do not recall telling (UM O or DON B) of the extra doses There was higher volume of stock of Glatiramer syringes in the refrigerator than normal. During an interview and record review on [DATE] at 3:53 PM, DON B stated, (LPN N) was officially let go today. She has not worked here at all this month. DON B texted the facility's scheduler for the last day the LPN worked which was [DATE]. DON B continued stating, At no time before (R102's) incident did I know (LPN N) was not passing medications. I was looking closely at her. I asked (LPN I) who brought it to my attention after [DATE] that the Glatiramer syringes were not being used. I asked (LPN I) directly if she had any ideas about the quantity of the Glatiramer that was left. She told me there was more there than should be. She thought (LPN N) was not giving the medications because there was more than should be. (LPN N) did not work at all in November (2023) and came back [DATE] (2023). She worked 5 times on (R102's) unit. She worked 10 times in [DATE]. After I questioned (LPN N) about the over number of syringes she started calling in. (LPN I) asked me to look into (LPN N) if she was giving mediations or not giving them because she speculated (LPN N) was not giving the medication. (LPN I) did not mention (R105) not getting medications from (UM O). I asked (LPN I) if she shared it with anyone else. She said she had not. I talked to her about she should have shared this earlier. It was either (LPN N or LPN I) giving (R102) the daily shot. I did not think it might be (LPN I) not giving it. I cannot think of any other nurse that talked to me about (LPN N) not giving medications. I asked (LPN N) some questions about medications, and she last worked [DATE]. She had inconsistencies in her job performance. Her work was getting sloppy. During an interview on [DATE] at 4:16 PM, UM O stated, I was the Unit Manager while (R102) was here at the facility. I did not know anything about her not getting her MS medication. No one said anything to me about her not getting it or of any other residents not getting their medications. I do fill in to give medications. During an interview on [DATE] at 4:30 PM, R105 reported she thought she was getting her medications. I'm not sure really what I get. I trust the nurse to give me what I need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1.) provide appropriate wound care treatment and preventions for 2 residents (Resident #112 and #4) of 2 residents reviewed for non-pressure related skin conditions and 2.) adequately identify and monitor a foot injury for 1 resident (Resident #109) of 1 resident reviewed for accident hazards, resulting in the actual worsening of diabetic ulcers for Resident #112, the potential of worsening wounds for Resident #4, and a delay in treatment for a foot injury for Resident #109. Findings include: Resident #112 Review of an admission Record revealed Resident #112 admitted to the facility on [DATE] with pertinent diagnoses which included cellulitis of left lower limb and diabetes mellitus with foot ulcer. Review of a Minimum Data Set (MDS) assessment for Resident #112, with a reference date of 8/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #112 was moderately cognitively impaired. Further review of same MDS assessment revealed Resident #112 required the assistance of one person with personal hygiene and bed mobility. Review of a current skin management Care Plan focus for Resident #112, initiated 8/22/2023, revealed resident was admitted to the facility with diabetic foot ulcers. Review of a current skin management Care Plan intervention for Resident #112, initiated 8/22/2023, revealed staff were directed to assist Resident #112 with floating his heels. Review of Resident #112's current active Physician's orders on 10/2/2023 at 3:07 PM revealed .paint (2nd) toe on right foot with betadine and cover with dry dressing change (every day) and (as needed) . betadine paint to bilateral heels (twice a day) . In an observation and interview on 10/2/2023 at 3:07 PM in Resident #112's room, Resident #112 was resting in bed with no dressing on his left or right foot. Resident #112's left foot heel had a black wound, and his left 2nd toe was black. Resident #112's heel and toe appeared to have betadine painted on them. Resident #112's heels were not floated. Registered Nurse (RN) JJ reported he painted betadine about 20 minutes ago and needed to check the order to verify whether a dressing was indicated. RN JJ reviewed the active orders and reported he would add a dry dressing. RN JJ reported the order for right 2nd toe dressing appeared to be incorrect and he would review this with the Assistant Director of Nursing (ADON). In an interview on 10/4/2023 at 8:46 AM, RN JJ reported Resident #112 did not have a dressing on his left 2nd toe wound on 10/2/2023 when he arrived that morning. RN JJ reported this was his first time taking care of Resident #112. RN JJ reported he had cleansed the wounds with normal saline and applied betadine paint upon arrival and was planning to check the treatment orders. In an interview on 10/2/2023 at 3:42 PM, ADON C reported the physician's order was placed incorrectly for the right 2nd toe and she was correcting the order to read the left 2nd toe. In a wound care observation and interview on 10/3/2023 at 7:47 AM in Resident #112's room, Wound Doctor H reported Resident #112 had significant vascular problems with his legs and could not feel his pedal pulses. Wound Doctor H reported resident had been referred for a vascular consult and wound treatment would continue as betadine on affected areas and covering the toes on left foot. Resident #112's heels were not floated. ADON C reported resident's wounds had worsened since admission, with the left 4th toe also being newly reddened. In an observation on 10/3/2023 at 3:41 PM in Resident #112's room, heels were not floated. In an interview on 10/4/2023 at 9:40 AM, ADON C reviewed Resident #112's wound measurement progression provided in a wound timeline. ADON C reported Resident #112's left heel and left 2nd toe have worsened. Review of wound measurements indicated Resident #112's left heel wound measured 2.2 by 2.3 cm when he admitted to the facility on [DATE] and measured 5.56 by 6.89 cm on 10/3/2023. In an interview on 10/4/2023 at 11:01 AM, ADON C reported Resident #112's order for right 2nd toe dressings was incorrect and this order was corrected on 10/2/2023 to the left 2nd toe. Resident #112's September Treatment Administration Record (TAR) revealed wound care was not documented as completed on 9/15/2023, 9/17/2023, 9/18/2023, 9/19/2023, the morning of 9/21/2023, the morning of 9/22/2023, the evening of 9/24/2023, or the morning of 9/26/2023. ADON C reported there is no documentation in the electronic medical record of these wound treatments being performed and there was no rationale documented regarding why they were not performed. ADON C reported she is managing wounds currently at the facility but is busy with many other duties as the facility is currently down 2 unit managers. ADON C reported she is responsible for placing all wound orders and is also the unit manager for the entire facility, with the help of the Director of Nursing. In an observation on 10/4/2023 at 11:21 AM in Resident #112's room, Resident #112 had no dressing on his left foot and his heels were not floated. In an interview on 10/4/2023 at 11:22 AM, Licensed Practical Nurse (LPN) S reported she was not aware the dressing was not in place. LPN S reported the nurse practitioner had looked at Resident #112's foot that morning but did not tell her that the wounds were left open to the air. In an observation on 10/4/2023 at 2:21 PM in Resident #112's room, Resident #112's heels were not floated. In an interview on 10/4/2023 at 2:30 PM, Certified Nursing Assistant (CNA) OO reported she was taking care of Resident #112. CNA OO reported she was not aware of any interventions being done for resident's feet or heels. CNA OO stated I don't know, the nurse would know. CNA OO stated I haven't seen his heels floated. In an interview on 10/4/2021 at 2:32 PM, LPN S reported she was not aware of any interventions for Resident #112 to float his heels. Resident #4 Review of an admission Record revealed Resident #4 admitted to the facility on [DATE] with pertinent diagnoses which included diabetes mellitus and chronic venous insufficiency. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 8/8/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #4 was cognitively intact. Review of a current skin management Care Plan focus for Resident #4, with a revision date of 8/14/2023, revealed Resident #4 was receiving treatment for chronic venous ulcers to his lower extremities. Review of Resident #4's Physician Orders active 10/2/2023 revealed .wash bilateral legs with soap and water, apply xeroform to open areas, apply ABD and wrap with kerlix, light compression ace wrap to legs at all times remove with cares, change daily and (as needed) . In an observation and interview on 10/2/2023 at 1:36 PM in Resident #4's room, Resident #4 reported staff had not changed his leg dressings in over 3 days. Resident #4 reported his dressings were ordered to be changed daily, but this was not taking place. Resident #4's legs were observed to have socks over ace wraps, with the top of the ace wraps stained with yellow and brown drainage. In an interview on 10/3/2023 at 8:36 AM, ADON C reported Resident #4 told her on 10/2/2023 that his dressings had not been changed since Thursday. Review of Resident #4's Treatment Administration Record (TAR) revealed Resident #4's leg dressings were not documented as being completed or attempted on 9/8/2023, 9/9/2023, 9/15/2023, 9/16/2023, 9/20/2023, 9/22/2023, 9/23/2023, and 10/1/2023. In an interview on 10/4/2023 at 9:55 AM, ADON C reported Resident #4's leg dressings are ordered to be completed daily. Review of facility policy/procedure Wound Management Program, revised 8/17/2023, revealed .Purpose . To eliminate, modify, or minimize factors that place residents at risk for skin breakdown . Policy . To assure that residents who are admitted with, or acquire, wound receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing . initiate treatment according to physician guidance . update care plan to reflect new risks and interventions . Resident #109 Review of an admission Record revealed Resident #109 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: type 2 diabetes mellitus (too much sugar in the blood) with diabetic neuropathy (nerve damage in legs and feet that causes pain). Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 8/9/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #109 was cognitively intact. In an interview and observation on 10/03/23 at 09:09 AM, Resident #109 was tearful and reported that her left foot and left big toe really hurt and stated, .I hurt it a couple months ago .I was lowering my bed and I smashed my foot . Observation of Resident #109's left foot revealed the end of the foot and the toes were purple. Resident #109 reported that she reported the injury immediately and had been telling facility staff for weeks that it wasn't getting better . Review of Resident #109's Physician's Note dated 7/14/2023 at 10:04 PM revealed, .Patient was seen for an persistent acute issues .Resident also reports that she injured her left great toe several days ago and now is having pain and swelling of her foot .ASSESSMENT/PLAN: .Left foot pain .Will place order for buddy taping left great toe and 2nd toe as well as icing TID (3 times a day) for 7 days. Continue tramadol (narcotic pain medication) as scheduled and acetaminophen (over-the-counter pain medication) . Discussed elevation of LLE (left lower extremity). Will continue to monitor. Review of Resident #109's Nurses Notes dated 7/28/2023 at 6:00 PM revealed, Late Entry: This resident c/o (complains of) pain in her right (sic) great toe. Noted the right (sic) great toe is swollen, purple in color and moderately painful. Medical provider to follow up with resident. In an interview on 10/04/23 at 11:01 AM, Resident #109 reported that her left foot and toe hurt all the time and she had not heard from facility staff about what the doctor was going to do. In an interview on 10/04/23 at 11:13 AM, Licensed Practical Nurse (LPN) F reported that Resident #109 injured her left foot about a month ago, and complains of pain frequently on second shift. LPN F reported that she asked Nurse Practitioner (NP) J about it on 9/29/23 and NP J was going to order an x-ray, but LPN F noticed as of that day the x-ray had not been completed. LPN F reported that she had spoke to NP J again and the orders were now in place for an x-ray. Review of Resident #109's Physician Orders revealed, 10/04/23 at 10:20 AM, review of new orders put in today: ok for right (sic) foot xray due to injury 2 mths (months) ago with persistent pain, discoloration, and swelling. No directions specified for order. Pending Confirmation. 10/4/2023 . In an interview on 10/04/23 at 11:17 AM, NPJ reported that she had seen Resident #109 a week ago and that was when the resident had first reported the foot injury that occurred 2 months ago. NP J reported that she ordered an x-ray and to apply ice and elevate the foot. NP J reported that she did not enter the orders in the computer until today. NP J did not recall having known about the injury previously, but then remembered once this surveyor referenced the visit notes from July 2023. In an interview on 10/04/23 at an unknown time, DON reported that NP J had changed Resident #109's x-ray to a STAT (immediate) order for today, and corrected the body site to left foot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DPS B Based on interview and record review, the facility failed to ensure resident safety in regards to fall prevention in 1 of 12 residents (Resident #327) reviewed for falls, when Resident #327 was not assessed for fall risk, the care plan was not adequately developed for current fall risk status and staff did not have sufficient knowledge of resident care needs, resulting in a fall, surgery and hospitalization for cervical (neck) spine fractures, and the potential for further decline in physical, mental and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #327 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Right BKA (below knee amputation), muscle weakness and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #327 was not available due to short 7 day stay. Review of Resident #327's Electronic Health Record indicated that he had a previous short stay in the facility and was discharged on 4/10/2020. Review of Resident #327 Incident Report dated 8/29/22 at 00:05 (12:05 A.M.) revealed, Patient yelling help. Nurse entered room, patient on floor. Patient fell out of bed, bed was high-had bed remote in hand. Patient was observed on back, complained of head and neck pain. Resident had been assisted with care approximately 10 minutes prior and staff had lowered bed to lowest position 911 called . Review of Resident #327's Hospital Records dated 8/29/22 revealed, ED (emergency department) to Hospital admission (CURRENT) .Chief Complaint: FALL, Assessment/Plan: DIAGNOSIS at time of disposition: 1. Fall from ground level .fracture of seventh cervical vertebra (spine) .fracture of first cervical vertebra . In an interview on 09/01/22 at 09:51 A.M., Licensed Practical Nurse (LPN) II reported that she heard a noise from Resident #327's room that sounded like the bed being raised up and stated, .I went in there and he was on the floor .his bed was very high . LPN II reported that Resident #327 said that he'd hit his head but did not complain of any pain, and his ROM (range of motion) and neuro's (neurological check) were normal. LPN II reported that she had never taken care of Resident #327 prior to that day, was not aware of his fall risk status, and in report she was told that he was confused and calling out for help a lot that day. In an interview on 08/31/22 at 03:25 P.M., Certified Nursing Assistant (CNA) GG reported that she was working when Resident #327 fell on 8/29/22 and stated, .I had just saw him on rounds around 11-11:30 P.M I didn't go in the room . CNA GG reported that she was not familiar with the residents that she was assigned to that night and stated, .the second shift CNA (CNA OO) and (LPN II) weren't familiar with the residents either . CNA GG reported that at the time of Resident #327's fall, she was on another hall talking to other staff and stated, .I was asking them if they knew anything about the patients . CNA GG reported that LPN II yelled for help from Resident #327's room and stated, .she (LPN II) wanted me to help her get him up off the floor .(LPN II) said that she was going to check him out .I knew better than to try to stand him up . CNA GG reported that she had trouble finding a hoyer lift that worked; CNA GG and CNA NN retrieved a hoyer lift and tried to transfer Resident #327 into bed, but he started saying that his head hurt and that he thought he needed a neck brace. CNA GG reported that she went and got LPN II and that's when they decided to send him to the hospital. This surveyor attempted to interview CNA OO on 09/01/22 at 08:44 A.M. CNA OO did not return the call. In an interview on 08/31/22 at 02:43 P.M., CNA U reported that Resident #327 was only in the facility for about a week before he fell and went to the hospital and stated, .he was very anxious .always calling out for help .he was scared . In an interview on 09/01/22 at 12:30 P.M., DON reported that she received a call from LPN II on 8/29/22 after Resident #327 was sent to the emergency room reporting that she had observed him on the floor. DON stated, .(Resident #327) has a lot of behaviors .he would call out for help a lot .he didn't like to be alone .I don't believe the behaviors contributed to his fall at all . DON reported that Resident #327 did not have a fall assessment on record and the care plan was not updated for falls. Review of Resident #327's Fall Risk Assessment, no fall risk assessment completed. Review of Resident #327's Fall Care Plan revealed, Risk for falls r/t (related to) hx (history) of Falls, Rt BKA. Date Initiated: 03/20/2020 Revision on: 08/25/2022. INTERVENTIONS: Assess and treat pain. Date Initiated: 03/20/2020 Revision on: 08/25/2022. Call light accessible. Date Initiated: 03/20/2020. labs/xrays. Date Initiated: 03/20/2020 Revision on: 08/25/2022. Orient to surroundings Date Initiated: 03/20/2020 Revision on: 08/25/2022. The care plan was revised from Resident #327's previous stay (>2 years ago). Review of Resident #327's Behavior Care Pan revealed, Behavior Trauma Date Initiated: 03/25/2020 Revision on: 03/25/2020. INTERVENTIONS: Concerns Include - Transportation Accident, Physical Assault, Severe Illness Triggers for Trauma Care include: persons with Alzheimer's Disease, bad weather Date Initiated: 03/25/2020 Revision on: 03/25/2020. There was no care plan related to Resident #327's current behaviors. Review of Resident #327's admission Assessment dated 8/23/22 at 18:23 (6:23 P.M.) revealed, .legally blind .ADL's .Bed mobility: Extensive Assist, Transfer: Total dependence .Pain: 4/10 .Location: buttocks .What makes the pain worse? laying in one spot .Mobility/Safety: .RT (right) BKA, use mech lift (hoyer lift) . Review of Resident #327's Nurses Note dated 8/28/2022 at 15:10 (3:10 P.M.) revealed, Resident having behaviors throughout late morning and early afternoon. Frequently yelling out for help, not using call light and being disruptive. RN tried talking to resident to stop behaviors and use call light. Talk ineffective as resident keeps yelling out for help. Review of Resident #327's Nurses Note dated 8/28/2022 at 12:01 P.M. revealed, Resident resting in bed. Less noted behaviors today, but still frequently cries out for help, and becomes emotional . Review of Resident #327's Nurses Note dated 8/27/2022 at 12:36 P.M. revealed, Resident crying and moaning during lunch, states he feels like he is going to throw up. Nurse went to get Zofran (medicine for nausea) while aide began changing resident. Resident became very agitated and upset with staff, stating he doesn't want to be man-handled twisted in knots or have someone shove their finger up my (word omitted). Staff educated resident that his brief was soiled with stool and that staff had to turn him to clean him up. Resident states he wants to call the state department and shut us down for not taking care of him. Resident also refusing Zofran because he doesn't know what he is being given, then begins crying . This citation pertains to intakes MI00129553, MI00129553, MI00129554, and MI00128817. This citation has 2 DPS Statements DPS A Based on interview and record review the facility failed to ensure a gait belt was used for 2 (Resident #273 and #53) of 12 residents reviewed for accidents and hazards resulting in bruising, and sprained right knee and hip. Findings include: Resident #273: During an interview on 08/31/22 04:08 PM, Director of Nursing (DON) B confirmed a gait belt should be used to get a resident off the floor or when assisting to stand up from a chair. DON B confirmed staff shouldn't have done either transfer (off the floor or out of chair) by grabbing Resident #273's wrists. Review of Resident #273's skin alteration assessment (incident/accident report; bilateral wrist bruising investigation), dated 6/27/22, stated, .Resident observed to have bruises to bilateral inner wrists .Resident states staff member placed hands of (on) wrists to assist her out of chair . Education provided to staff on proper transfers .Injuries Observed at Time of Incident .Injury Type .Bruise .Notes: Resident noted to have a small bruise on the thumb side of her right and left wrist. Review of Resident #273's nurse progress note, dated 6/28/22, .Resident states that she was assisted up from her reclining chair. Resident states that she then observed slight bruising to her wrist the next day .Orders per MD (medical doctor) to observe area and monitor for healing. Review of Resident #273's physician progress note, dated 6/27/22, stated, .Staff states that she fell recently while up ambulating on her own .Was also noted that when the patient was lifted off the floor staff grasped bilateral wrist to pull her up and she now has bruising on the wrist. Patient notes minimal pain of the wrist .Injury to bilateral wrists with ecchymosis (discoloration of skin; typically bruising). Review of Resident #273's nurse progress note, dated 6/28/22, stated, Reported that cena (certified nurse aide) found 2 bruises dark purple to left and right wrist. resident (Resident #273) not sure what happen. Cena noted them yesterday. Review of Resident #273's activities of daily living care plan, revised 7/7/22, stated, transfer 1PA (one person assist) . Review of Resident #273's brief interview for mental status score, dated 4/16/22, was scored 5 which reflected severe cognitive impairment. Review of the facility's transfer techniques policy, dated 7/1/2008, stated, Purpose: To transfer a resident safely .Use gait belt or other transfer devices . R53 According to the Minimum Data Set (MDS) dated [DATE], R53 scored 12/15 on her BIMS (Brief Interview Mental Status) had clear speech making her needs known, understood others, required extensive assistance of two-plus persons physical assistance to transfer on/off toilet, was not steady moving from a seated to standing position; only able to stabilize with staff assistance, used a walker or wheelchair for locomotion, had no impairment in her upper or lower extremities, with diagnoses that included bipolar disease, COVID-19, and morbid obesity. Review of R53's Incident Report #1215 dated 6/30/2022 14:36 (2:36 PM) reported the resident had a fall in her bathroom during transfer. CNAs stated they lowered the resident to the floor when resident's legs got weak. R53 stated her right knee was twisted and refused to allow staff to get her up. Resident requested EMT and visit to ER. R53 is her own person. An ambulance was called. Level of pain was 3/10 and was ambulatory with assistance after incident. Resident was oriented to person, situation, place, and time. Review of R53's Care Plan 4/8/2022 Risk for Falls related to hypertension, osteoarthritis, and OAB. Reported the goal set was to minimize injury related to falls by assessing and treating pain. Review of R53's Care Plan 5/3/2022 ADL (Activities-of-Daily Living) deficit, reported the goal set was to participate in ADLs daily with an intervention that included Hoyer (mechanical lift) for transfers initiated 4/8/2022 and revised on 7/19/2022 (transfer specify 1, 2 PA (person assist), full lift, sit to stand (mechanical lift) initiated 4/8/2022). During an interview on 8/31/2022 at 2:30 PM R53 stated, I fell in the bathroom while not wearing a gait belt. I needed to go to the bathroom. (CNA O and CNA N) came to help me. I told them I could not walk but I could walk before I got Covid a few weeks before. I still cannot walk. With the CNAs, I stood up to pivot and asked them for a gait belt right away. They told me no, it was almost time to pass trays. I kept insisting for a gait belt and they said they did not have time. I used the bathroom then turned on the red call light and waited. It took me a while to use the bathroom and that was okay; they went to pass lunch trays. I do not know how long it was. When (CNA O and N) came back to help me I stood up and I tried to pivot. I did not have a gait belt on. I could not move my legs or the walker. My right knee went out and I went down. The CNAs said I did not fall. I did not want the mobile x-ray to come to me. I did not want facility staff to evaluate me. The ambulance, fire department, and EMS came. I am obese so the fire department got me up. I went to the ER, and they did an x-ray on my knee and hip and told me I had a knee and hip sprain. I know it was the facility's fault I fell. They did not put a gait belt on me. During an interview on 9/01/22 at 11:43 AM, DON B stated, (CNAs O and N) were transferring (R53) from the toilet to her wheelchair. The resident told the staff her legs were getting weak, and staff slid her to the ground. Depending on resident's wishes, a gait belt is used. If a resident does not want a gait belt, they do not have to have one used. I do not know if a gait belt was used when (R53) fell in the bathroom. I do not remember her being on the toilet for one and a half hours. During an interview on 9/01/22 at 12:58 PM, CNA N stated, (R53) said she had to use the bathroom while (CNA O) and I were passing lunch trays. We told her we were passing lunch trays, but she insisted she go to the bathroom, so we put her on the toilet. (R53) rang the call light from the bathroom within 10 minutes. (R53) did not fall. (CNA O) was in front of the resident and I was behind her with the wheelchair. We told her to step back into the chair. She said No, I'm going to fall to the ground, and we guided her down. We did not use a gait belt with her. I do not know what her transfer status was then but now she is officially a mechanical lift. During an interview on 9/01/22 at 1:36 PM Registered Nurse (RN) I stated, (R53) was lowered to the floor by two CNAs (N and O) in the bathroom. I was not in with the resident during the incident but right after it happened. (R53) was being transferred from the toilet to the wheelchair by the two CNAs without a gait belt. There should always be a gait belt in use when a resident is being transferred when not using a mechanical lift. The resident did not want staff to move her or evaluate her. I evaluated her the best I could and what she would allow. EMS came to move her off the floor and took her to the hospital. Review of R53's Progress Note Review of R53's Progress Note 6/30/2022 14:47 (2:47 PM) reported the resident had a fall in bathroom during a transfer. The CNA's stated they lowered the patient to the floor. Resident stated her right knee twisted. Patient refused staff to get her up. Patient requests EMT and visit to ER to assess knee. Review of R53's Progress Note 6/30/2022 21:02 (9:02 PM) Physician's Note .Staff reported the patient was sitting on the toilet for approximately an hour and a half. When staff went to help her get up and get back into bed, she had a fall. She states she landed on her right knee and is having significant pain there .Staff attempted to get the patient off the floor, but she refused. Patient feels unsafe with anyone but EMT getting her off the floor. She is requesting to be transferred to the emergency department .sitting on the restroom floor .There is tenderness with palpation and patient yells out with attempts at range of motion .Fall with pain to the right knee. I did encourage the patient to allow staff to get her off the floor and to obtain an x-ray in-house. Patient refused this recommendation and requested transport to the emergency department. EMS was called for transfer and further evaluation workup in the ED (emergency department) . Review of R53's Hospital After Visit Summary dated 6/30/2022 reported the resident sustained a sprained right knee and hip for a fall at the facility.