**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA) timely for one (Resident #91) of 20 reviewed for Minimum Data Set (MDS). Findings include: Review of the clinical record reflected Resident # 91 (R91) was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic kidney disease. R91's Minimum Data Set (MDS) dated [DATE] reflected a BIMS of 4. Review of R91's monthly physician orders revealed a physician order for hospice dated 12/16/24. Hospice notes dated 12/16/24 revealed R91 was admitted on to hospice care as of 12/16/24. Further review of R91's clinical record revealed the SCSA MDS was initiated on 01/13/25 (incomplete as of 1/14/25). On 01/14/25 at 02:01 PM, during an interview with MDS Nurse D she acknowledge the SCSA MDS should have started in December when R91 was signed onto hospice care. MDS Nurse D offered no explanation why the Significant Change MDS was late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit Minimum Data Set (MDS) assessments to Centers for Medicare & Medicaid Services (CMS) timely for two (Resident #49 and #89) of 20 reviewed. Findings include: Resident #49 (R49): Review of the medical record reflected R49 admitted to the facility on [DATE], with diagnoses that included diabetes and dependence on renal dialysis. R49's MDS history reflected a discharge return not anticipated MDS, with an Assessment Reference Date (ARD) of 8/31/24, which was completed on 9/11/24. The MDS had not been transmitted to CMS. Resident #89 (R89): Review of the medical record reflected R89 admitted to the facility on [DATE], with diagnoses that included aftercare following surgery for neoplasm (abnormal growth of tissue). R89's MDS history reflected a discharge return not anticipated MDS, with an ARD of 8/30/24, which was completed on 9/11/24. The MDS had not been transmitted to CMS. In an interview on 01/14/25 at 2:00 PM, MDS Nurse D reported the facility had 14 days from the date of MDS completion to transmit the MDS data to CMS. MDS Nurse D acknowledged that R49 and R89's discharge return not anticipated MDS assessments had not been transmitted to CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate coding on a Minimum Data Set (MDS) assessment for one (Resident #96) of 20 reviewed. Findings include: Review of the medical record reflected Resident #96 (R96) admitted to the facility on [DATE], with diagnoses that included wedge compression fracture of the second thoracic vertebra. The discharge return not anticipated MDS, with an Assessment Reference Date (ARD) of 12/9/24, reflected R96 was coded for discharge to a short-term hospital. A Progress Note for 12/9/24 reflected R96 discharged home. In an interview on 01/15/25 at 12:03 PM, MDS Nurse D reported R96 discharged home, not to the hospital. MDS Nurse D acknowledged there was a coding error on the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to confirm that the Pre-admission Screening And Resident Review (PASARR Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation prior to their admission to the facility for 1 residents (#83) of 2 reviewed. Review of the clinical record reflected Resident # 83 (R83) was admitted to the facility on [DATE] with diagnoses that include morbid obesity and bi-polar disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Status Score of 15 out of 15 (cognitively intact). The mood section of the same MDS reflected R83 felt down, depressed or hopeless several days a week. Review of R83's clinical record reflected a 3877 dated 2/26/24 revealed R83 had a mental illness diagnosis and received psychotpic medication that included an anti-psychotic medication. Review of the 3878 dated 2/28/24 and signed by the physician reflected R83 was admitted on an exemption and would likely need less than 30 days of nursing home care. A second 3877 dated 11/22/24 signed by the facility MDS Nurse D reflected R83 had a mental illness and received psychotropic medications. Further review of the clinical record revealed no documentation that CMH was aware of R83's admission 6 months prior. On 01/14/25 at 03:10 PM, during an interview with Social Worker (SW) M reported R83 had a level II completed by another county. When queried why it was not in the medical record SW M offered no explanation. A request to review R83's Level II completed by CMH was requested at that time. SW M stated there was some confusion regarding the status and would follow up with surveyor tomorrow. On 01/15/25 at 12:07 PM, during an interview with MDS Nurse D she reported she was not responsible for tracking when 3877/3878's were due, she just completed them when notified to do so by the facility's Social Work Department. On 01/15/25 at 12:25 SW M reported R83 was at another facility in another county for several months prior to being admitted at their facility. R83 stayed well beyond the 30 day exemption at the other facility and CMH in the other county started a Level II evaluation but did not complete it. When queried how/why R83's 3877/3878 screen completed in February 2024 determined to be acceptable 4 months after the exemption period SW M offered no explanation. When queried why the facility did not complete a second 3877 screen until 4 months after R83's admission, SW M offered no explanation.

Based on observation, interview and record review, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized for contact precaution and ensure hand hygiene was performed for four (Resident #22, 26, 52, and 57) of reviewed for contact precautions. Findings include: On 1/13/25 at 10:34 AM, a contact precaution sign was observed outside of the room of Resident #22 (R22) and Resident #57 (R57). The contact precaution sign indicated that hand washing prior to entry of the room, as well as donning a gown and gloves (PPE) was necessary prior to entering the room. On 1/13/25 at 10:37 AM, a contact precaution sign was observed outside of the room of Resident #26 (R26) and Resident #52 (R52). The contact precaution sign indicated that hand washing prior to entry of the room, as well as donning a gown and gloves was necessary prior to entering the room. In an interview on 1/13/25 at 10:38, Licensed Practical Nurse (LPN) P stated that both rooms were contact precautions due to a gastroenteritis virus that was affecting the residents. LPN P confirmed that hand hygiene should be performed and a gown, and gloves needed to donned prior to entering the room. Upon exit, staff should be discarding the PPE in a trash receptacle inside the room and performing hand hygiene. On 1/13/25 at 10:43 AM, Staff member T was observed entering the room wearing gloves and not performing hand hygiene where R26 and R52 resided. Staff member T changed the liner in the trash receptacle and exited the room wearing the same gloves and without performing hand hygiene. Staff member T proceeded to obtain a broom, and reenter the room wearing the same gloves and without performing hand hygiene. Staff member T swept the floor from the doorway to the opposite side of the room. Staff member T proceeded to exit the room wearing the same gloves and without performing hand hygiene, obtained a mop, and reentered the room with the same gloves and without hand hygiene. Staff member T mopped the room in the same manner, crossing over both sides of the room. Stall member T exit the room wearing the same gloves and without performing hand hygiene, and proceeded down the hall. On 1/13/25 at 11:11 AM, staff member S entered the room of R22 and R57 without performing hand hygiene or donning required PPE. Staff member S exited the room without performing hand hygiene. On 1/13/25 at 11:13 AM, staff member S entered the room of R26 and R52 without performing hand hygiene or donning required PPE. Staff member S exited the room without performing hand hygiene and proceeded down the hallway with a laundry cart. On 1/13/25 at 11:15 AM, staff member S entered a resident room without performing hand hygiene and exited shortly after without performing hand hygiene. In an interview on 1/13/25 at 11:18 AM, staff member S stated that hand hygiene, gown and gloves are required when entering a contact precaution room. Upon exit, discard the PPE inside the room and perform hand hygiene. Staff member S confirmed that she did not don PPE in either contact precaution rooms and denied performing hand hygiene upon entry and exit. On 1/13/25 at 12:43 PM, Certified Nursing Assistant (CNA) U was observed entering the room of R26 and R52 to deliver a glass of apple juice without performing hand hygiene or wearing proper PPE. On 1/13/25 at 12:47 PM CNA U was observed entering the room of R26 and R52 to deliver a lunch tray. CNA U did not perform hand hygiene or don the required PPE. On 1/13/25 at 12:47 PM, CNA F observed CNA U in the room without the required PPE and advised that she step out and don the required PPE. CNAU stated that she was not aware of the need for contact precautions in the room. Review of Physician Order's revealed R52 and R57 were both under contact precautions for gastroenteritis type symptoms. In an interview on 1/15/25 at 1:06 PM, Registered Nurse (RN) O confirmed that she was responsible for the infection control program in the facility. RN O stated that staff should be performing hand hygiene, donning required PPE of gown and gloves prior to entering the rooms of R22, R26, R52, and R57. Staff should be doffing the required PPE of gloves and a gown, and performing hand hygiene upon exiting he room. RN O stated that the required contact precautions should be followed even if staff is momentarily entering the room to drop an item off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00146126: Based on observation, interview and record review the facility failed to meet the needs of residents with regard to the timeliness of providing laboratory services and reporting laboratory results for one residents(R104) of three residents reviewed for medications, resulting in delayed treatment and intervention related to lab results, and impaired coordination of care. Findings include: Resident #104(R104) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included history of deep vein thrombosis/pulmonary embolysis(blood clot), hypertension (high blood pressure), pelvic fracture, dementia, chronic kidney disease, anxiety and depression, The MDS reflected R104 had a BIM (assessment tool) score of 7 which indicated her ability to make daily decisions was severely impaired, and she required maximal physical assist with toileting, bathing, dressing, and moderate assist with hygiene and dependant on staff for bed mobility. During an observation and interview on 8/20/24 at 1:18 p.m. this surveyor entered facility with signs posted on front entry that reflected positive Covid cases starting 8/16/24 with all staff wearing facial masks. Nursing Home Administrator A reported the current census was 91 residents. During an observation and interview on 8/20/21 at 2:05 p.m., during the facility initial tour, this surveyor entered R104 room after permission was granted by R104 and family. R104 was sitting up in wheelchair with her husband at the bedside. R104 appeared pleasantly confused with poor memory recall with simple questions. R104 husband F reported R104 was at the facility for rehabilitation after accident with broken pelvic bone. R104 husband F reported was upset with care at facility because he had spoken with physician over two weeks ago and had reported concerns with R104 swelling in both feet, symptoms of urinary tract infection(UTI) and concerns about not being able to regulate Coumadin dosing. R104's husband F reported physician assured family concerns would be addressed but nothing happened until physician returned yesterday and family was again upset about continued concerns. R104's husband F reported compression socks were then applied and informed medications could cause changes in Coumadin dosing and reported medication had not changed until yesterday when antibiotic was started for UTI. R104's husband F reported routinely visited facility twice daily. Review of R104 complete Medical Record, dated 7/18/24 through 8/22/24, reflected no evidence of prothrombin time/international normalized ratio (PT/INR)(measures how long it takes blood to clot) flowsheet. Review of R104 Physician Progress Note, dated 8/22/24 at 7:59 a.m., reflected, LABORATORY . INRs 7/29/24 INR 4.1 - Coumadin 5 mg daily put on Hold 7/30/24 INR 3.45 7/31/24 INR 2.8 - Start Coumadin 3 mg daily 8/02/24 INR 2.1 - Continue Coumadin 3mg daily 8/05/24 INR 1.73 - Increase Coumadin to 4 mg daily 8/12/24 INR Not drawn 8/14/24 INR 2.57 8/15/15 INR 3.50 Hold Coumadin x 1dose (16th) Given 17th, 18th. 8/19/24 INR not drawn. Coumadin given on 19th, then held. 8/21/24 INR 1.44 Start Coumadin 4 mgMWF 3 mg STTHSat. Repeat 7/26[8/26/24]. Discussed with Nurse and Nurse Manager. Review of R104's Medication Administration Record(MAR), dated 7/18/24 through 7/31/24, reflected R104 received Coumadin (blood thinner) dosing as noted below as indicated by staff initials: Dates of 7/18/24 through 7/29/24(including 7/29/24)-Coumadin 5 mg 1 tablet daily at 5:00 p.m. On 7/30/24-Coumadin dose was on HOLD(not given) On 7/31/24-Coumadin 3mg daily started Review of the MAR, dated 8/1/24 through 8/22/24, reflected R104 received Coumadin dosing as noted below as indicated by staff initials: 8/1/24 through 8/5/24 Coumadin 3 mg daily 8/6/24 through 8/15/24(including 8/15/24) Coumadin 4mg daily 8/16/24 Coumadin dose was on HOLD 8/17/24 and 8/18/24 Coumadin 4mg daily 8/19/24 through 8/20/24 Coumadin dose on HOLD 8/21/24 No Coumadin given(hole on MAR) 8/22/24 Coumadin 4mg one time dose given at 11:54 a.m., Coumadin 3mg dose given at 5:00 p.m.(total 7mg Coumadin) Review of the Laboratory Report, dated 7/31/24, reflected R104 had PT/INR collected with results of 2.8. The report included Physician hand written note that included, Coumadin 3mg daily INR on Friday[8/2/24]. No Physician Order was located in R104 Medical Record. Review of the Physician Orders, dated 8/3/24, reflected R104 had an order for PT/INR to be drawn on 8/5/24. Review of the Contracted Laboratory Report, collected on 8/5/24 at 12:14 p.m., reflected R104 PT/INR results were 1.73 (oral anticoagulant therapeutic range 2.00-3.00 according to report). The report included Physician had written undated note that included, Increase Coumadin to 4mg daily .INR 1 week R104 did not receive increased Coumadin dose until 8/6/24 evening. Review of the Physician order, created on 8/6/24, reflected R104 had an order for PT/INR to be drawn 8/12/24. Review of R104 Complete Medical Record reflected no evidence of Physician ordered PT/INR on 8/12/24 had been completed. No evidence Physician had been notified was located. Review of the Contracted Laboratory Report, collected 8/14/24, received 8/15/24, reflected R104 PT/INR was 2.57. No physician order was located for 8/14/24 lab draw that was three days after physician ordered request. Review of the Contracted Laboratory Report, collected 8/15/24, received 8/15/24, reflected R104 PT/INR was 3.50. R104 had labs drawn both 8/14/24 and 8/15/24 that were both received to the lab and reported to the facility on 8/15/24. The 8/15/24 report included the Physician hand written note that included, 8/14/24 INR 2.57 INR not drawn today put Coumadin on hold . No physician order was located for 8/15/24 lab draw that was three days after physician ordered request. Review of R104 Nursing Progress Note, dated 8/15/24 at 2:49 p.m., reflected, INR-2.57. Call placed to [named provider] and orders received to continue Warfarin 4mg QD. Recheck INR on 8/19/24. The rest of the labs faxed per provider request. Review of R104 Physician Progress Note, dated 8/15/24 at 3:22 p.m., reflected, Reviewed resident's labs. INR was 2.57. Continue current Coumadin dose and recheck level on Monday [8/19/24] Review of the Physician orders reflected no evidence of repeat PT/INR for R104 on 8/19/24 was created. Review of R104 Physician Progress Note, dated 8/16/24, reflected, Labs were drawn again today and reviewed. Sodium is improve at 146 from 148. Other labs are stable. PT/INR was 36.0 and 3.50. Instructed the nurse to hold tonight's dose. The resident is discharging tomorrow, so redraw can not be done on Monday. Nurse is to give the most recent INR level to SW to fax to PCP. Resident should follow-up with PCP. Review of R104 Physician Progress Note, dated 8/19/24 at 5:22 p.m., reflected, Follow up: Seen at daughters request re: confusion and increased edema .ASSESSMENT & PLAN .R/O UTI: She has confusion, some lower abdominal discomfort, and very cloudy urine. UA C&S ordered. Foley is for urinary retention .Hx DVT: Hx reviewed. Hx left DVT after hip surgery in 2015. Hx right DVT about 1-2 years ago. On one of these occasions, she had pulmonary emboli. INR late last week 2.57-3.5 and one dose of Coumadin held. INR not drawn today as ordered - believe it best to hold Coumadin and repeat INR on Wednesday. Husband had questions about why INR was so variable .Daughter [named] left before I had the opportunity to answer my questions. She expressed a lot of dissatisfaction about care . Review R104 Physician Progress Note, dated 8/21/2024 at 12:28 p.m., reflected Brief follow up at request of nurse/husband .UA obtained on 8/19 as ordered. I started Cipro at that time because in my opinion benefits outweighed risks. Symptoms improved. Unfortunately, due to lab issue, UA was not picked up and had to be discarded. Repeat UA was obtained today, but she has been on antibiotics so results will not likely be helpful for decision making. Complete Cipro . During an interview on 8/22/24 at 1:20 p.m. Registered Nurse (RN) G reported facility was no longer able to use local hospital lab related to cost and reported changes were made about one month ago. RN G reported facility was only allowed to use lab company American Health Associates(AHA) based out of Florida that only comes to facility every Monday, Wednesday and Thursday. During an observation and record review on 8/22/24 at 2:02 p.m., observed Oak Hall Lab binder located at the nurse station. Review of the binder reflected R104 had a printed order for PT/INR on 8/12/24(Monday) with R104 listed on the, iPowerDoc Daily Log, for labs 8/9/24 to 8/12/24, printed 8/9/24, with no documentation that phlebotomist has drawn ordered labs. The Log included 11 other residents with orders and no documentation that had been drawn that day. Continued review of the binder with log dated, 8/14/24, printed 8/13/24 at 1013 pm., reflected R104 had bmp, cbc, pt/inr drawn on 8/14/24 according to initials from phlebotomist. Continued review of the binder reflected R104 had an order entered on 8/19/24 at 6:40pm for STAT urinalysis with culture and sensitivity(UA with CS) lab company American Health Associates(AHA) out of Florida requested by facility staff. (No evidence of UA with CS located in R104 medical record). Continued review reflected R104 was on the 8/21/24 ipowerdoc daily log dated 8/21/24 printed 2:40 pm. signed by phlebotomist with comments picked up urine spec. Continued review of the Lab Binder reflected R104 had orders for repeat PT/INR for 8/19/24 that were not on the lab log that was printed 8/13/24 at 3:46 p.m.(Seven days prior to lab draw 8/19/24, and two days prior to R104 Physician order entry on 8/15/24 for PT/INR. Review of the Physician Order, dated 8/19/24, reflected R104 had an order for UA and CS. During an interview on 8/22/24 at 2:30 p.m., Clinical Care Coordinator(CCC) H reported was R104 CCC and was not present on 8/12/24 and reported was unsure if 8/12/24 labs were collected by contracted lab but appeared several residents had orders with no lab staff initials. CCC H reported contract lab comes to facility every Monday,Wednesday and Thursday only unless Physician orders STAT orders. CCC H reported if labs are not drawn the day the physician ordered the labs draws on the next scheduled day (Monday, Wednesday, Thursday). During an interview on 8/22/24 at 3:25 p.m., CCC H reported was unsure why R104 PT/INR was not draw on 8/19/24 as ordered but was later collected 8/21/24 on the next contracted lab scheduled day. During an interview on 8/22/24 at 3:40 p.m., R104 family I verified R104 Coumadin dose was stable at home prior to admission and facility has not been able to regulate and reported goes from sub-therapeutic to elevated with no medication changes until 8/19/24. During an interview and record review on 8/22/24 at 5:00 p.m., Nursing Home Administrator (NHA) A and Nurse Consultant(NC) K verified Director of Nursing (DON) B was out of facility that week. NHA A and NC K reported would expect labs to be completed as ordered. NC K verified contracted lab company obtains labs on Monday, Wednesday or Thursdays unless STAT labs ordered. NC K reported contracted lab company does not allow labs to drawn by staff and labs to be taken to other lab facilities. NC K verified facility had issues with contracted lab company related to staffing concerns with timeliness of labs and results. NC K verified facility did not use Coumadin Flow sheets, however, planned to implement moving forward. NC K reported R104 had an order for PT/INR on 8/12/24 that was not completed until 8/14/24 related to lab issues and scheduled days. NC K reported was unable to locate Physician order for 8/15/24 PT/INR and reported staff would enter order with contracted lab but not facility Physician order and would need to provided staff education to enter Physician order. NC K verified R104 had Physician order for PT/INR on 8/19/24 not completed until 8/21/24(two days later for blood thinning dose monitoring). NC K verified AHA (contracted lab) followed printed orders and log on day of lab draws that should be printed close to date. NC K verified labs for 8/19/24 were printed 8/13/24 (several days prior) and verified R104 was not listed on page (orders entered either 8/14 or 8/15). NC K provided documents that reflected R104's UA & CS ordered STAT on 8/19/24 at 6:31 p.m. was picked up by Lab on 8/20/24 at 9:57 a.m. and was dropped off at the lab 8/20/24 at 6:34 p.m.(24 hours later speciman was delivered to the lab). During an interview on 8/22/24 at 5:40 p.m., NC K reported lab was at the facility on 8/12/24 but was unable to obtain labs from a few residents and would provide evidence of communication. Surveyor did not receive evidence of missed Physician ordered labs prior to exit for R104 on 8/12/24. During an interview on 8/22/24 at 5:56 p.m., NHA A reported was responsible for the Quality Assurance and Performance Improvement meetings at the facility and the topic of labs challenges had been discussed that included no negative outcomes but there was not a performance improvement project started to date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #86 (R86) On 12/18/23 at 11:24 AM R86 was observed lying on back in bed and during an interview he stated facility staff had told him he had to buy his own briefs if he wanted a larger sized bariatric brief. In review of R86's Minimum Data Set (MDS) with an assessment reference date of 8/17/23 revealed he was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a cognitive screener, score of 15 (13-15 Cognitively Intact). The same MDS revealed R86 was occasionally incontinent of bowel and bladder and had not been in a toileting program. In review of R86's electronic medical record (EMR), he was 311.8 pounds (lbs.) on 08/10/23 and is most recent weight was 288 lbs. on 12/07/23. R86's same EMR revealed R86 had the diagnoses of morbid obesity, pulmonary disease, heart disease and abdominal aortic aneurysm (AAA) enlargement in the aorta (main vessel through which oxygen-rich blood travels from the heart to the rest of the body) that extends through the abdomen. Nursing Home Administrator (NHA) A was interviewed on 12/19/23 at 11:41 AM and stated there was a criteria used for residents to determine need for bariatric brief and if a resident did not meet criteria, and the resident requested the bariatric sized briefs, the facility would provide bariatric briefs. NHA A stated it was the first he had heard of an issue with residents' brief sizes. During an interview on 12/19/23 at 1:04 PM R86 stated he was told by numerous facility staff that he had to buy his own briefs if he wanted a bariatric size; and was explained to him that it was a corporate decision. Certified Nurse Assistant (CNA) V was interviewed on 12/19/23 at 1:07 PM and stated he was told R86 did not meet bariatric guidelines for bariatric briefs. CNA V stated he did not tell R86 that he had to purchase his own bariatric briefs. Licensed Practical Nurse/Unit Manager (LPN) U was interviewed on 12/19/23 at 1:19 PM and stated last month he obtained measurements (weight/height/waist) for residents. LPN U stated the facility would supply bariatric briefs for R86 if he wanted them. During an interview on 12/20/23 at 8:41 AM, R86 stated he was grateful he received the bariatric briefs and used them yesterday during the night. R86 stated the smaller briefs the facility had provided previously left red marks because they were to tight and when he turned in bed the briefs would un-fasten. Based on observation, interview, and record review the facility failed to accommodate two out of four residents (Resident #81 and 86) with briefs that fit them, resulting in red marks and painful skin irritation. Findings Included: Resident #81 (R81): Review of R81's electronic medical record revealed R81 was recently admitted to the facility on [DATE]. R81 had a diagnosis of, MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES. Review of a BRIEF INTERVIEW OF MENTAL STATUS assessment dated [DATE], revealed R81 scored a 15 out of 15, which indicated R81 had no impairment in her cognition. In an interview on 12/18/2023 at 9:45 AM, R81 stated that her briefs were too small. R81 said she had asked staff (could not recall names of staff) several times for the larger size brief, but said staff told her corporate had to approve her to have a larger size brief. During the interview an observation of R81's dresser drawer revealed the drawer was full of yellow briefs. The briefs did not have the size marked on them. R81 stated the yellow briefs was what she and other residents were given, because that was all the facility had available. R81 also said that the yellow briefs caused a sore in her groin area, because they were to small. In an interview on 12/19/2023 at 9:11 AM, Certified Nurse Aid (CNA) C said the yellow briefs were the XX large (extra extra large), and those were the briefs R81 wore. CNA C said R81 did complain that the yellow briefs were too small. CNA C also said that the Velcro straps (used to hold the brief together while wearing) for R81's briefs could not be pulled all the way up to the middle of the brief, because the yellow briefs were to small for R81. CNA C further stated that R81 had red areas where the edges of the brief rubbed on her skin. CNA C said lotion had to be put on her skin when a new brief was put on for skin protection. CNA C said the facility used to have the 22 bariatric size, but said those were not available anymore, and she did not know why. In an interview and observation on 12/19/2023 at 9:36 AM, R81 stated that she had some red marks located on her skin in the area where her brief was. An observation of R81's skin and brief revealed the Velcro was not able to be pulled up to the middle of the brief, but had to be attached to the side of the brief. CNA C stated the Velcro had to be attached on the side so the brief so it was not too tight, and the Velcro would just come apart. Observation of R81's skin revealed two long raised red marks on R81's right groin area, and on R81's left groin a large area was observed to have red irritated skin right where the edge of the brief touched her skin. R81 stated that her left groin area was painful where her skin was red and raw. In an interview on 12/19/2023 at 10:32 AM, Central Supply (CS) D employee said that it had been about two weeks ago when the bariatric size briefs were removed from the supply closet. CS D said she would have to fill out a request form, send it to corporate to get approval to order the bariatric size for R81. CS D said measurements of R81's hip and waist area had to be documented, and R81's measurements did not meet the criteria for use of the bariatric size, so she was provided with the yellow briefs size XX large. CS D said R81 would be provided with the next size brief if her skin was red and irritated from the yellow briefs, but said no one ever told her that R81 had skin irritation/redness from the yellow briefs being to small. In an interview on 12/19/2023 at 11:42 AM, Administrator A stated that the bariatric briefs could not be ordered unless the resident met the criteria, which was based on the resident's height and weight. Administrator A said if a resident was experiencing red and raw skin because of the brief being too small, then the resident would be given a bariatric size brief even if they did not meet criteria. In an interview on 12/19/2023 at 11:46 AM, Regional Clinical Coordinator (RCC) E said if a resident needed a bigger size brief a request form would be filled out and sent to the supplier for approval, if the resident met the criteria for bariatric size briefs. RCC E said an order override could be done if a resident needed bariatric briefs but did not meet the criteria. In another interview on 12/19/2023 at 12:39 PM, CNA C stated that she did tell other staff members about one month ago of R81's skin in her groin area having red marks and skin irritation from the briefs being too small. Other staff members also cared for R81 and were aware of the problem. In an interview on 12/19/2023 at 1:02 PM, Director of Nursing (DON) B said that today was the first time a request form was sent out for approval for bariatric briefs for R81. DON B stated that she was never informed that R81's skin was red and irritated from the yellow briefs being to small.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent pressure ulcers in 1 of 2 residents reviewed for pressure ulcers (Resident #251), resulting in pain, wound treatments, and the potential for additional skin breakdown and infection. Findings include: Resident #251 (R251) During an observation and interview on 12/18/23 at 10:21 AM with R251's family member, R251 was admitted to the facility for rehabilitation after she fell and fractured her left leg at home. R251's family member stated R251 had developed a blister on her left heel while a resident at the facility. R251 was observed lying in bed on her back with her heels directly resting on her mattress. In review of R251's admission assessment dated [DATE], R251 did not have any wounds or reddened areas. R251's Skin assessment dated [DATE] revealed no new wounds. In review of R251's Skin Management Care plan dated 12/08/23, she was at risk for skin breakdown due to weakness, impaired mobility, pain, high blood pressure, lung disease, dementia, incontinence, and heart disease. The same care plan initiated on 12/08/23 revealed R251 had a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough, may also present as an intact or open/ruptured serum-filled blister) to her left heel with treatment in place. The same care plan instructed to assist R251 with floating her heels. In review of R251's electronic medical record, there were no measurements of her Stage 2 pressure ulcer on her left heel, description of the wound bed, or type and amount of drainage. R251's Skin assessment dated [DATE] indicated she had one new wound. R251's Physician Order dated 12/10/23 revealed to cleanse left heel with wound cleanser, pat dry, apply barrier skin prep around wound (to protect skin outside of wound). Apply foam dressing with boarder. Change every day and as needed for open area. R251's Brief Interview for Mental Status, a short performance-based cognitive screener, score was 00 (00-07 Severe Cognitive Impairment). In review of R251's nurses note dated 12/11/23 at 12:00 PM, blanchable erythema (redness) noted to resident's left heel. New orders given to discontinue current treatment and apply Aquacel heel foam dressing (combination dressing- hydrocolloid with absorbent material that transforms into a gel on contact with wound fluid, with ionic silver to manage serosanguinous fluid) every 5 days for protection. Resident made aware of new orders and in agreement with current plan of care. On 12/19/23 at 8:45 AM R251 was observed sitting in the dining room, feet resting on foot pedals, wearing non-skid socks. On 12/19/23 at 11:59 AM R251 was observed sitting in a wheelchair in lobby wearing socks and feet were resting on foot pedals. During an observation on 12/20/23 at 10:52 AM R251 was observed lying in bed. Unit Manager/Licensed Practical Nurse (LPN) U removed dressings wrapped around her left heel and heel presented with an open blister, had drainage and a red wound bed. LPN U measured R251's pressure ulcer. Certified Nurse Assistant (CNA) W was interviewed on 12/20/23 at 11:06 AM and stated R251 had an open blister on her left heel and thought it had been there since she was admitted . LPN U was interviewed on 12/20/23 at 11:14 AM and stated R251's left heel was 3.1 cm by 3.3 cm. LPN U stated on 12/11/23 a nurse documented R251 had a blister on her left heel, and no photos were taken. LPN U stated the wound nurse looked at R251's pressure ulcer on 12/11/23 and her heel was blanchable erythema. (Stage 1 pressure ulcer was defined as non-blanchable erythema). During an interview with wound nurse (WN) I on 12/20/23 at 11:23 AM she stated she looked at R251's left heel on 12/11/23 and it was blanchable erythema and intact. WN I stated a dressing was ordered for prevention of skin breakdown. WN I was unable to explain why the R251's skin on her heel was to be cleansed with a wound wash cleaner.

Based on observation, interview, and record review, the facility failed to provide supplements and fortified foods to prevent weight loss in one of one residents reviewed for weight loss (Resident #91), resulting in a severe weight loss of 7.8 pounds. Resident #91(R91) admission History and Physical dated 11/09/23 and Dietary Profile dated 11/10/23 revealed R91 had a history of heart disease, kidney disease, arthritis, bone loss, moderate protein-calorie malnutrition and history of gastric bypass 28 years prior. R91 had been admitted to the facility following a hospitalization for pneumonia and respiratory failure. R91 was alert and oriented to person and place only. R91 received supplements twice a day during her hospitalization and took a protein supplement when at home. R91 did not have any swelling of her extremities. R91's current weight was 125 pounds (lbs.) and her ideal body weight was 135 lbs. The same Dietary Profile indicated when R91 was made aware of her current weight of 125 lbs., she responded by asking for pie. Physician's order with start date of 11/09/23 indicated R91 was to be provided supplements and fortified foods (boosted nutritional value) per dietary. R91's nutritional care plan dated 11/09/23 indicated her goal was to maintain stable nutritional status with adequate intake and weight would be stable within 5 percent (%) of lbs. Weight change progress note dated 11/17/23 at 4:21PM, R91's weight was 119 lbs.; and had lost 6 lbs. in one week. The same note indicated intravenous fluids received during hospitalization may have contributed to weight loss. The same note indicated R91's usual body weight was 114 lbs., per her daughter. Weight Change note dated 12/13/23 at 2:46 PM revealed a weight warning, R91's weight was 116.2 lbs., a loss of 8.8 lbs./ 7 % in one month. Weight change note dated 12/15/23 at 10:07 AM indicated R91's weight was 111.2 lbs., 7.8-pound weight loss in one month; and a juice supplement would be provided twice daily. R91 was observed on 12/19/23 at 8:58 AM sitting at a table with other residents. A staff member was observed going table to table, offering residents oatmeal from a soup kettle. R91 was offered and accepted oatmeal from the same soup kettle, in which other residents were served from. In observation of entire breakfast meal, no dietary supplements or fortified foods were offered to R91. On 12/19/23 at 12:48 PM, R91 was offered and accepted Cabbage soup with crackers, from soup kettle that all residents were served from. No other supplements/fortified foods were offered to R91. On 12/20/23 at 8:58 AM R91 was observed sitting in the dining room eating breakfast with a glass of cranberry juice. Dietary Manager X was interviewed on the same date and time and stated they had juice supplements on the drink cart in the dining room, and confirmed R91 had not received her juice supplement. Staff then provided juice supplement to R91 and to other residents in the dining room. Registered Dietitian (RD) H was interviewed on 12/20/23 at 9:13 AM and stated some of R91's weight loss was anticipated because of IV fluids received in the hospital last month and she had a diuretic medication. RD H stated staff knew R91 had supplements because it was on her food ticket. When asked how do the CNA's know R91 was to receive fortified oatmeal and a juice supplement when the oatmeal, soups and drinks were passed before the main meal, with the food ticket; RD H stated she would go around and check that everyone received their supplements that dietary provided. RD H confirmed she was not present at every meal. RD H confirmed R91 was to receive fortified oatmeal, it was a different recipe and would come directly from the kitchen.

Based on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable practice for maintaining controlled medication for two out of five medication carts resulting in the potential for controlled medication diversion. Findings Included: During observation of the Cedar One medication cart on 12/20/2023 at 09:12 a.m. it was observed that the facility Controlled Accountability Record for this medication cart was last signed by only the out going nurse at 06:30 a.m. on the date of 12/20/2023. The signature box for the on coming nurse was blank. In an interview on 12/20/2023 at 09:37 a.m. Licensed Practical Nurse (LPN) M explained that she was the on coming nurse that took control of the Cedar One Medication cart on 12/20/2023 at 06:30 a.m. LPN M explained that it was policy that controlled medication was to be counted between the on coming nurse and the outgoing nurse when there was a change in the nurse that controlled the medication cart. She explained that once the controlled medication count was completed, the numbers are recorded, and both nurses would sign in the appropriate box of the Controlled Accountability Record . LPN M confirmed that she had not signed as the on coming nurse. LPN M explained that she had forgotten to sign once the count was completed. During observation of the Maple Hall medication cart on 12/20/2023 at 09:43 a.m. it was observed that the facility Controlled Accountability Record for this medication cart was last signed by only the out going nurse at 06:30 a.m. on the date of 12/20/22023. The signature box for the on coming nurse was blank. In an interview on 12/20/2023 at 09:44 a.m. Licensed Practical Nurse (LPN) O explained that she was the on coming nurse that took control of the Maple Hall medication cart on 12/20/2023 at 06:30 a.m. LPN O explained that it was policy that controlled medication was to be counted between the on coming nurse and the outgoing nurse when there was a change in the nurse that controlled the medication cart. She explained that once the controlled medication count was completed, the numbers are recorded, and both nurses would sign in the appropriate box of the Controlled Accountability Record . LPN O confirmed that she had not signed as the on coming nurse. LPN O explained that she has forgotten to sign once the count was completed. In an interview on 12/20/2023 at 09:48 a.m. Director of Nursing (DON) B explained that it was policy that controlled medication was to be counted between the on coming nurse and the outgoing nurse when there was a change in the nurse that controlled the medication cart. She explained that once the controlled medication count was completed, the numbers are recorded, and both nurses would sign in the appropriate box of the Controlled Accountability Record . DON B explained that signature of both nurses would be an attestation of an accurate count for that medication cart. DON B could not explain why the Controlled Accountability Record had not been signed by the on coming nurse, at 0:630 a.m. on 12/20/2023, for the Maple Hall medication cart and the Cedar One medication cart. Review of the provided facility policy 4.2 Medication Storage Controlled Medication Storage, dated 2007, demonstrated #6 At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurse or per state regulations and is documented on the controlled accountability record or verification of controlled substance count report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately completed Minimum Data Set (MDS) assessments for one (Resident #28) of 18 reviewed, resulting in inaccurate assessments and the potential for unmet care needs. Findings include: Resident #28 (R28) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R28 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension(high blood pressure), hearing loss, dementia without behaviors, mood disorder, cerebral vascular accident(stroke), anxiety, depression, +Covid and recent fall with fracture to left lower leg. The MDS reflected R28 had a BIMS (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, locomotion on unit, dressing, toileting, hygiene, bathing and two person assist with transfers. During an observation and interview on 9/20/22 at 2:00 PM, R28 was sitting in reclined broda chair in Dining room facing television with eyes open and ortho boot on left lower leg and appeared thin with moist productive cough noted. R28 appeared calm and not able to answer questions. During an interview on on 9/20/22 at 2:37 PM, R28 was laying in low positioned bed on back with mats on both sides of the bed. During a telephone interview on 9/21/22 at 8:54 AM, R28's Durable Power of Attorney(DPOA) CC reported concerned about R28's recent fall from the bed with left foot fracture when R28 never used feet. DPOA CC reported prior to Covid about 1.5 weeks ago had visited several times each week but had not been able to visit as frequent since Covid outbreak. DPOA CC reported was told by staff that R28's floor mats were not in place at the time of the fall on on 7/18/22 and R28 had increased pain after fall. Review of the Electronic Medical Records, dated 7/1/22 through current(9/22/22), reflected R28 had several areas of documented increased pain including Progress Notes, Medication Administration Record(MAR), and Hospice Notes post fall on 7/18/22 that resulted in fracture. Review of the MAR, dated 7/1/11 through 7/31/22, reflected R28 received 12 doses of as needed Norco(narcotic pain medication) between 7/18/22 and 7/30/22 and none prior to 7/18/22(date of fall with fracture.) Review of the Nurse Progress Note, dated 8/2/2022 at 8:00 p.m., for R28, reflected, resident continues on scheduled and PRN norco, resident observed yelling out, physician notified and wants to continue with current pain treatment at this time as it was recently increased. Review of the RAI Note, dated 8/4/2022 at 9:28 a.m., for R28, reflected, DOCUMENTATION RELATED TO RAI PROCESS / SKILLED COVERAGE (admission / SIG. CHANGE / DISCONTINUATION):: MDS quarterly assessment completed for this resident with no significant changes noted this quarter. Continues to reside at the facility for long term care secondary to care needs related to Dementia. Hospice services in place with [named hospice]. Requires extensive to dependent assistance with ADLS, bathing, and toileting tasks. Hoyer lift for transfers. Broda chair in place for seating and locomotion. Always incontinent of bowel and bladder. Assisted with incontinence care as needed. Wears a brief for dignity and protection. Skin intact. Pressure reducing device in place to bed and wheelchair. Skin assessed daily with care and weekly with nursing assessment. Per staff occasional pain related to recent fracture. Pain medication effective for pain management. Resident had one fall during the look back period (5/4/22-7/28/22) with major injury. No dental concerns upon inspection. No adverse reactions to daily medication regimen. Based on data collected for MDS assessment, along with staff and resident interviews conducted, resident continues to qualify for skilled nursing care at this facility by passing through Door 1 of the Michigan Medicaid LOCD. During an interview on 9/23/22 at 8:44 AM, MDS Registered Nurse(RN) JJ reported working as MDS nurse for 2.5 years. RN JJ reported collect information from resident Medical Records to complete MDS assessments including orders, MAR, assessments(forms in EMR), talk to staff including staff who often care of for R28. RN JJ reported MDS assessment for R28 with RAI dated of 8/4/22 staff interview was completed and reported was unsure who she spoke with. MDS RN JJ verified R28's MDS with RAI date 8/4/22 reflected R28 had no pain. During an interview on 9/23/22 at 9:00 AM, MDS RN JJ reported R28 look back was 7/23/22 to 7/28/22 and locked on 8/4/22 and staff reported no pain (5 day period was just after left fibula fracture identified on 7/22/22 with several documented entries of increase pain in EMR). Review of the Pain Care Plan, last revised 5/31/22, for R28, reflected, I am not be able to verbalize my pain, but may exhibit non verbal signs of restlessness or crying out. I have chronic pain secondary to history of CVA and generalized pain. I have pain medication in place. The pain care plan reflected no updates after 7/18/22 fall with fracture and increased pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a baseline care plan to include dialysis and accurate medications for one (Resident #224) of 18 reviewed, resulting in the potential for unmet care needs. Findings include: Review of the medical record revealed Resident #224 (R224) was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, diabetes, seizures, and end stage renal disease. R224 was dependent on renal dialysis. Review of the Brief Interview for Mental Status (BIMS-cognitive screening tool) dated 9/17/22 revealed R224 scored 15 out of 15 (cognitively intact). On 09/20/22 at 01:25 PM, R224 was observed sitting in a wheelchair in her room. R224 reported the nurse that morning had no idea what to do. R224 reported she had dialysis that morning and the nurse did not have any of the paperwork ready. R224 reported she asked the nurse to write the basic information such as her name and vital signs on a piece of paper. R224 reported on the night of 9/19/22, she was told she would be woke up at 4:00 AM for a 5:30 AM transport time on 9/20/22. R224 reported staff did not wake her up until 5:00 AM, which made her very upset. R224 reported the transport driver had to high tail it to dialysis and that she was five minutes late for her scheduled dialysis time. Review of R224's baseline care plans, revealed there was not a care plan for dialysis until 9/20/22, which was three days after R224 was admitted to the facility. Review of the anticoagulation care plan initiated 9/20/22 revealed an intervention of Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. Review of a Physician's Order dated 9/17/22 revealed R224 was on Aspirin 81 milligrams per day. In a telephone interview on 09/21/22 at 11:53 AM, Certified Nursing Assistant (CNA) R reported there was miscommunication in shift-to-shift report regarding R224's dialysis transport time on 9/20/22. CNA R reported R224's pick up time was supposed to be 5:45 AM, but she was told 6:45 AM. CNA R reported paperwork was not prepared to send to dialysis with R224 and therefore R224's name, room number, and vital signs were written on a piece of paper. In an interview on 09/21/22 at 12:15 PM, Registered Nurse (RN) S reported she was the Minimum Data Set (MDS) nurse. RN S reported baseline care plans were initiated within 48 hours of admission and included all pertinent care plans, for example activities of daily living, discharge plan, pain, and medications. RN S agreed that R224's dialysis care plan was initiated three days after admission, on 9/20/22. When asked why R224's care plans did not mention dialysis until 9/20/22 (3 days after admission), RN S reported she would have to check to see if dialysis was a requirement of the baseline care plan. In a telephone interview on 09/21/22 at 01:46 PM, RN T reported she was supposed to do R224's dialysis paperwork/communication form on 9/20/22, but she didn't know how. RN T reported R224 was given a piece of paper with her vital signs listed. RN T reported she was not aware of the time R224 was to be transported to dialysis but knows that R224 left at 6:08 AM on 9/20/22. RN T reported the aide also did not know what time R224 was supposed to leave that morning because R224 was a new admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for one resident (Resident #28) out of 18 residents, resulting in the potential for unmet care needs. Findings include: Resident #28 (R28) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R28 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension(high blood pressure), hearing loss, dementia without behaviors, mood disorder, cerebral vascular accident(stroke), anxiety, depression, +Covid and recent fall with fracture to left lower leg. The MDS reflected R28 had a BIMS (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, locomotion on unit, dressing, toileting, hygiene, bathing and two person assist with transfers. During an observation and interview on 9/20/22 at 2:00 PM, R28 was sitting in reclined broda chair in Dining room facing television with eyes open and ortho boot on left lower leg and appeared thin with moist productive cough noted. R28 appeared calm and not able to answer questions. During a telephone interview on 9/21/22 at 8:54 AM, R28's Durable Power of Attorney(DPOA) CC reported concerned about R28's recent fall from the bed with left foot fracture when R28 never used feet. DPOA CC reported prior to Covid about 1.5 weeks ago had visited several times each week but had not been able to visit as frequent since Covid outbreak. DPOA CC reported was told by staff that R28's floor mats were not in place at the time of the fall on on 7/18/22. Review of the facility Fall Incident Report, dated 7/18/22 at 12:45 a.m., for R28, reflected, Incident Description Nursing Description: Notified by another Nurse that Res rolled out of bed and was on the floor. She was laying on her right side on the side of the bed closest to the doorway .Resident unable to give description . The Report included CNA HH statement that reflected, CNA had just finished changing Res and walked out to get a blanket for her. When he came back into the room the Res had rolled out of bed and was on the floor. The Report included notes that reflected, She in ext. assist of one for transfers .Will continue winged mattress and bed in lowest position while in it . Continued review of the Report included note, dated 7/22/22, that R28 had X-Ray that showed fractures of the left 1st metatarsal base and left distal fibula fracture. Review of the Nursing Progress Note, dated 7/18/22 at 1:20 a.m., for R28, reflected, 0100 Notified by another Nurse that Res had rolled out of bed and was on the floor. CNA had just finished changing the Res, he left the room to get a blanket and when he returned the Res was on the floor, laying on her right side on the side of the bed facing the door. No injury noted, no bruising, redness, skin tear or open areas noted. Res assisted into bed w/ a 2 staff assist. Norco given at 0108 for s/sx of general discomfort. Neuro-checks initiated, VSS. Res currently resting in bed comfortably. Progress note was created by Registered Nurse (RN) DD. Review of the Nursing Progress Note, dated 7/19/2022 at 6:04 a.m., for R28, reflected, CNA stated that resident was guarding right arm when turned for brief change. Resident stated you broke it as she was turned. Resident scored 6/10 on PAINAD scale. PRN Norco administered at 0502. After administration, resident stopped yelling out and rocking from side to side. Medication effective. Score reassessment 2/10 on PAINAD scale. Review of the Hospice Collaboration Form, dated 7/19/22 at 1:30 p.m., reflected Hospice Home Health Aid visited R28 with plans to provided bath and documented, bath not given due to pain from recent fall . Review of the Nursing Progress Note, dated 7/19/2022 at 2:03 p.m., for R28, reflected, [named] hospice nurse here at this time and notified by this nurse of resident having fall on 7/18/22 at 0045, and that PRN norco has been given twice since then for c/o pain. Resident assessed by hospice nurse at this time, and resident showed s/s of pain with movement of left leg/hip with facial grimacing, and moaning. Hospice nurse spoke with DPOA son [named DPOA CC] to discuss care of resident and he stated that he would like an x-ray of left hip. This nurse then called [named physician] to notify, and order noted for x-ray of left hip 2 view stat. Review of the Nurse Progress Note, dated 7/19/2022 at 9:15 p.m., for R28, reflected, Resident has no c/o pain at this time. Resident does c/o pain when left leg and hip are moved. Neuro checks wnl. This nurse spoke with [named physician] to report left hip XRAY findings: No acute fracture or dislocation .[named physician] advises to also order a 2 view XRAY of the right hip and a 3 view XRAY of the right shoulder. Review of the Nurse Progress Note, dated 7/22/2022 at 2:06 p.m., for R28, reflected, This nurse was called into the residents room to look at left foot and observed it is swollen and bruised. [named physician] in to see patient notified of swelling and bruising of the left ankle and cough and sputum doctor ordered chest xray and ankle and foot xray to be done STAT. Non weight bearing on left leg also ordered. this nurse elevated the foot and put ice pack on it. Review of the Nurse Progress Note, dated 7/22/2022 at 11:23 p.m., for R28, reflected, X-Ray results confirm fracture of left distal tibia and left 1st metatarsal. Physician viewed x-ray results and spoke with hospice. Decision was made not to send patient to hospital. Dr increased Norco[pain medication] to BID[two times daily] and orders to be placed for surgical boot. Follow up x-rays in 4-6 months. Spoke with residents son by phone and he is agreeable with plan of care . During an observation on 9/22/22 at 8:14 AM, R28 was laying in low bed with eyes closed and mats on floor on both sides of bed with washcloth over forehead. During an observation on 9/22/22 at 9:59 AM R28 continued to be in same position in bed, eyes closed, low bed, 2 mats on floor with washcloth on forehead. During an observation and interview on 9/22/22 at 1:20 PM, R28's DPOA CC was at R28's bedside with several other visitors. DPOA CC reported he had received call from the facility early that morning related to R28's recent decline and unresponsive. R28 was lying in bed with eyes closed and washcloth over forehead. During an interview on, 9/22/22 at 1:28 PM, Licensed Practical Nurse (LPN) G reported was not present at the time of R28 fall but worked next day and was responsible for documenting neuro checks and post fall Progress Note. LPN G reported facility policy was to document every shift for 72 hours after a fall. During an interview on 9/22/22 at 2:30 PM, Hospice Certified Nurse Aid (CAN) EE reported after each visit she documented on blue communication form in hospice binder. CNA EE verified provided R28 bathing services every Tuesday and Friday and had visit 7/26/22 and 7/29/22 and surgical boot was removed during bath. CNA EE reported nurse [named RN FF] had more detailed records from visits. During a telephone interview on 9/22/22 at 2:55 PM, Hospice RN FF reported assessed R28 on 7/19/22 after the fall and reported R28 was non-verbal and unable to say where pain was initially. RN FF reported R28 was very painful after fall and pain medication added. RN FF reported R28 developed bruising 7/22/22 to left ankle and X Ray was ordered that indicated fracture. RN FF reported delay with boot because facility thought Hospice would provided and boot and they did not and verified boot placed 7/26/22. RN FF reported first made aware of R28 suspected deep tissue injury on the left heel on 8/2/22 reported by facility RN GG. Review of the Fall Care Plan, dated 10/12/18, for R28, reflected, I am at risk for falls due to history of falls, severe cognitive impairments related to dementia and history of CVAs, incontinence, significant osteoporosis , osteopenia. I have poor safety awareness and may lean over in my chair or scooch in my bed towards the edge. I am receiving hospice services and an expected decline is expected .Interventions .Bed in low position when in bed. Date Initiated: 07/27/2022 .BILATERAL FLOOR MATS to be in place while in bed. Date Initiated: 06/02/2021 . Review of the EMR on 9/23/22 at 8:30 a.m., reflected R28 passed away that morning. During a telephone interview on 9/23/22 at 12:19 PM, RN L reported was present at the time of R28 fall on 7/18/22. RN L reported CNA HH was providing care and stepped out of R28 room to get a blanket and returned and R28 had rolled out of bed. RN L reported arrived to R28 room and observed R28 laying directly on the floor on her left side with no floor mat in place and bed was positioned at waist level. RN L reported was not R28 nurse at that time but was in the area charting when she was alerted of R28 fall. During an interview on 9/23/22 at 1:15pm, uncertified Nurse Assistant ([NAME]) II reported worked 7/18/22 day shift after R28 fall. [NAME] II reported was told R28 had fall from bed but not provided details about the fall but reported received reinforcement education that fall mat should be in place of residents are in bed and bed should be in lowest position should be standard practice. During a telephone interview on 9/23/22 at 1:20 PM, RN DD reported did complete R28's fall Incident Report on 7/18/22 at 12:45 a.m. and reported was unsure how R28 was transferred off the floor. RN DD reported was not present at time of fall because she was also working on another hall at that time. RN DD reported had spoke with CNA HH who reported had left R28's room after providing care to get blanket and R28 was on the floor when he returned. RN DD reported did not recall if she asked if fall mats were in place or what the position of bed was. RN DD reported thought manager did investigation. During an interview on 9/23/22 at 1:50 p.m., Director of Nursing (DON) B reported started employment at the facility on 7/18/22. DON B reported aware that falls were an issue and had noticed immediate actions taken on I/A reports were resident assessments and should reflect what was done prevent further falls. DON B verified resident assessments do not not prevent falls. DON B reported that now either herself or Administrator A review all I/A reports prior to being locked. During a telephone interview on 9/23/22 at 2:25 PM, CNA HH reported left R28 room to get a blanket after care and heard R28 make sound in room, returned to room, and found R28 on the floor moaning. CNA HH reported RN DD was nurse at time but was wrap nurse and was on the other hall at the time of the fall. CNA HH reported RN L assisted him to get R28 back to bed and reported was unable to recall if fall mats were in place at the time of the fall and reported R28 should have been a two person assist. During an interview on 9/23/22 at 2:56 PM, DON B reported would expect staff to include as many details as possible on fall reports including if ordered care planned interventions were in place or not at the time of the fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #19 (R19) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R19 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included renal disease, anxiety, and depression. The MDS reflected R19 had a BIM (assessment tool) score of 4 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, walking, locomotion on unit, dressing, toileting, hygiene, and bathing. During an observation on 9/22/22 at 8:16 AM, R19 was noted to have signs on door that reflected enhanced precautions. R19's door was open and resident in room appeared to be resting. During an observation and interview on 9/20/22 at 1:47 PM, R19 was standing in the doorway of room independently repeating, help me, help me. R19 reported pants were wet and reported needed assistance. R19 call light was observed on as indicated by light on wall in room(no hall light noted). Staff were noted going in and out of Dining Room about 25 feet from R19 room with no response to R19 shouting, help me or activated call light. Certified Nurse Aide (CNA) AA passed R19 room in hall and reported she was one of two CNA staff working on that hall and left area with out answering R19 call light or looking in room at 1:51 p.m Male CNA staff continued to move residents from Dining Room while R19 continued to be on at 01:53 p.m. At 1:56 p.m. R19 self ambulated back to bed and yelled, Help, that's the same one.(referring to this surveyor). At 2:00 p.m. Infection Control Nurse (IC) C passed R19 room and asked if she needed assistance after R19 yelled for help and entered room.(15 minutes after this surveyor observed R19 yelling for help and call light being on). Review of the facility Resident Matrix, dated 9/20/22, reflected R19 had recent fall with injury. Review of the Nurse Progress Notes, dated 9/9/22 at 6:00 a.m., for R19, reflected, Late Entry: DOCUMENT RELEVANT INFORMATION ABOUT THE RESIDENT:: This nurse was called into resident room by CNA, upon arrival resident was observed lying on her back on the floor beside her bed. On the side of the bed that the window is on. Resident stated she was trying to go to the bathroom. resident assisted to her feet by staff members and walked to the bathroom, vital signs taken and neuro-checks initiated, skin assessed .Created Date : 9/11/2022 04:18:13. Review of the Nurse Progress Note, dated 8/7/2022 at 6:49 p.m., for R19, reflected, Resident in bathroom having self transferred, without her walker and resident has several wash rags on the floor trying to wipe up urine. This nurse assisted resident with clean brief. This nurse washed resident's shoes that had urine on them and cleaned up bathroom. Resident reminded to use her call light. This nurse assisted resident back to bed. Resident had eaten 51-75% of her dinner which consisted of only mashed potatoes. Pleasant. No c/o pain. Review of the facility provided Incident/Accident(I/A) Reports, by the Director of Nursing (DON) B reflected the following falls for R19: -I/A reported dated, 8/31/22 at 5:36 p.m., reflected R19 was observed by staff self ambulating in room and attempted to redirect R19 and R19 tripped over own feet and staff lowered R19 to the ground. The report reflected, Immediate action taken-Description: res. assessed; ROM and VS WNL; physician and guardian notified/ res put into her bed and reminded to use her call light when she needed help . -I/A report dated, 8/15/22 at 4:15 p.m., reflected R19 was observed by floor tech staff slide off bed and land on bottom next to bed with call light on resulting in skin tears to right arm. The report reflected under Immediate Action that R19 was assessed and right arm skin tears were treated with no mention of interventions to prevent further falls with possible injury. Continued review of report reflected notes written on 8/18/22 to prevent further falls staff will check with resident and offer to toilet every two hours while awake. -I/A report, dated 7/18/22 at 8:30 p.m., reflected R19 had an unwitnessed fall in hall near the lobby(entire length of Maple hall, past nurse station and Dining Room from R19 room) while independently ambulation without assist and without 2 wheeled walker. The reported reflected under immediate action that R19 was assessed and physician notified with no mention of interventions to prevent further falls. Continued review of the report reflected notes written on 7/18/22 that included R19 required one person assist with use of 2 wheeled walker and had fall day prior on 7/17/22 after recent admission. The notes reflected physician order to obtain orthostatic blood pressures. -I/A report, 7/17/22 at 2:27 p.m., reflected R19 had an unwitnessed fall in bathroom after staff left R19 alone in bathroom. The reported reflected no immediate actions taken and notes included new intervention to not leave resident alone while in there bathroom. The provided I/A reports did not reflected detained information for complete and though investigation including when residents last cared for(toileted, observed), if care planned interventions were in place or not, and did not reflect evidence actions were taken to prevent further falls with possible injuries. No I/A Reports were provided for 9/9/22 or 8/7/22. Review of R19 ADL Care Plans, dated 7/14/22, reflected, I have an actual ADL deficit secondary to impaired mobility related to falls in the home setting, syncope, AKI, anxiety, and cognitive impairments .Interventions .AMBULATION: One person limited assist using 2ww[two wheeled walker]. Date Initiated: 07/15/2022 . Continued review of the Care plans reflected, Falls due to recent admission/new environment, syncope, chronic kidney disease, anxiety, mild neurocognitive impairments, impaired mobility, altered mental status, impulsive, wandering behavior, impaired right eye vision, and diarrhea .Revision on 8/5/22 .Do not leave me alone while I am on the toilet. Date Initiated: 07/17/2022. I will wear non-skid footwear for all transfers and walking. Date Initiated: 07/14/2022 .Orthostatic B/P's Date Initiated: 07/14/2022 . Review of the Care Plans revealed no mention of interventions added after 7/18/22. Review of the R19 Fall Assessment Note, dated 9/9/22, reflected, Resident is a [AGE] year old woman admitted on [DATE] for Rehab following hospitalization at [named] Hospital for worsening confusion. She is at risk for falls r/t new environment, syncope, CKD, anxiety, neurocognitive impairment, altered mental status, impulsiveness, wandering behavior, impaired vision in right eye, and diarrhea. She is able to ambulate with assist of one and walker. She requires two persons for toileting with pant management. She had previous falls on 7/17/22 and 7/18/22, 8/15/22, 8/31/22. on 9/9/22 0700 resident observed on the floor by the window side of the bed. She states she was attempting to use the bathroom. Call light was not on and feet were bare. Resident had no injuries and was assisted to the bathroom and then back to bed. She didn't have gripper socks on. Resident was given gripper socks. Her only shoes are crocs at this time. Resident has recently been declared not her own person and a guardian was appointed. Will call DPOA for different shoes. During an interview on 9/21/22 at 4:55 p.m., DON B verified did have I/A reported for 9/9/22 that had been in progress. DON B reported an I/A reported was not completed for R19 8/7/22 fall and should have been. During an interview on 9/23/22 at 1:50 p.m., DON B reported started employment at the facility on 7/18/22. DON B verified was unable to locate R19 orthostatic blood pressures ordered after 7/18/22 fall and reported did not see changed made to the R19 Care Plan after 8/15/22, 8/31/22, or 9/9/22 fall. Based on observation, interview and record review the facility failed to develop interventions that meet current standards and add them to the plan of care after each fall for two (R19, R30) out of 18 reviewed for revising care plans resulting in the potential for continued falls with minor injury, falls with severe injury or death. Findings include: R30 A review of the Minimum Data Set (MDS - resident assessment), dated 8/1/22, reflected R30 was admitted to the facility on [DATE] with diagnoses that included history of breast and lung cancer, irritable bowel syndrome with diarrhea, vascular dementia with behaviors, psychosis and moderate cognitive impairment, stroke with right hemiplegia (difficulty moving extremities, especially right arm) and hemiparesis (difficulty feeling extremities), History of thoracic vertebrae fracture, depression, anxiety, osteoarthritis, congestive heart failure and seizures. A review of the Activities of Daily Living (ADLs) plan of care reflected R30 required limited assist of one staff person with four-wheel walker for ambulation and transfers, and one staff person extensive assist for showers. Care plan interventions for R30 about falls: dated 3/2/22 were assess and treat my pain, non-skid footwear for all transfers and walking, labs/x-rays, medication reviewed by pharmacist, orient to surroundings, orthostatic blood pressures and therapy referral as needed. Dated 4/30/22 resident re-educated on use of call light to request assistance for transferring. Dated 5/2/22 was resident re-educated to ensure her wheelchair brakes are locked before any transfer in or out of her chair. A review of the facility policy titled Fall Reduction Program, last revised on 9/25/16, reflected: Procedure 2. Implement and indicate individualized interventions on Care Plan/[NAME]. 3. If fall occurs Charge Nurse to complete the following .Immediate interventions as identified by physical assessment and environmental observation .3.1 Initiate safety interventions and update care plan as applicable .3.3 IDT [interdepartmental team] to review each incident to complete root cause analysis .3.4.3. Identify any additional interventions in the Care Plan/[NAME]. A review of fall investigation reports reflected R30 had several falls. Each fall, intervention and if the care plan was updated during a discussion with Director of Nurses (DON) B on 9/23/22 at 1:25 pm as follows: On 8/2/22 at 5:30 am R30 raised the head of her bed, attempted to get into her wheelchair and missed it. There were no injuries. The intervention was to demonstrate call light to use to call for help. This intervention was already entered on 4/30/22 and the date was not updated. DON B did not see this on the care plan since this fall. On 8/8/22 at 7:42 pm R30 was found sitting on the floor of her bathroom. The indwelling catheter was removed that day. There were no injuries. Repeated interventions were demonstrate call light and call staff for help. A new intervention was therapy to assess and treat for toilet transfers which was already in the care plan without an updated date. DON B said no new intervention were added to the care plan until later. On 8/17/22 supervise on toilet was added. On 8/21/22 at 1:00 pm R30 was found on the bathroom floor after attempting self-transfer to the wheelchair. R30 said she was waiting for her aide to get additional help to get off the toilet. There were no injuries. The interventions were turn on call light, maybe yell for help and wait for help/supervision which were already on the care plan. DON B said there were no new interventions. On 9/7/22 at 3:53 pm R30 was yelling for help and observed face down on the bathroom floor. R30 sustained a small skin tear on the forehead. The intervention to supervise on toilet was added, and DON B agreed and said the aide was fired after multiple warnings about supervision to prevent falls for R30.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and provide pressure ulcer care consistent with professional standards of practice, in 2 of 3 residents (R28 and R44) reviewed for pressure ulcers, resulting in 2 unstageable pressure ulcers, the potential for delayed healing and decreased quality of life. Findings include: Resident #44 (R44) Review of the medical record revealed Resident #44 (R44) was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, diabetes, legally blind, right sided weakness from a stroke, stage 3 kidney disease and cognitive communication deficit. R44 required assistance for all care related to the mild to severe weakness on his right side. Review of the Brief Interview for Mental Status (BIMS-cognitive screening tool) dated 08/22/22 revealed R44 scored 15 out of 15 (cognitively intact). During an interview on 09/21/22 at 08:55 AM with R44, discussion regarding him having a wound or sore. I don't know, they haven't said anything to me about it. During a record review on 09/22/22, it reflected that on 08/19/22, R44 had an in-house acquired pressure ulcer on Right Lateral Malleolus (right ankle) unstageable (full thickness tissue loss in which actual depth of ulcer was completely obscured by slough and or eschar in the wound bed) documented as being minutes old, measuring Area 1.63 centimeters (cm), Length 1.68 cm, width 1.33 cm by wound care nurse C. Was not able to obtain wound care orders for this wound on this date. Wound description of wound bed had slough (pale cream/tan in color, non-viable fibrinous tissue that needed to be removed) percentage of Slough 10%, percentage of Eschar 90% (Brown/black crust collection of dead tissue where blood no longer reached a portion of the wound) Exudate (fluid that moved from site of injury from the circulatory system in response of local inflammation) Amount, Light Serous drainage, no odor with cleansing using a generic wound cleaner. Debridement Autolytic (removal of necrotic debris and devitalized tissues from a wound through a moist environment that facilitates the bodies own healing), Primary Dressing is an antimicrobial (an agent that kills microorganisms or stops their growth), covered with a foam dressing. Additional Care included use of a cushion, foam mattress, heel suspension, protection device with a turning/repositioning program. Record review also reflected this same pressure ulcer was assessed on 08/24/22, measured Area 2.25 cm, increased in size by 38 %, Length 2.13 cm, increase in size by 26 %, Width 1.52 cm increase in size by 14 %, as documented by wound care nurse C. Wound assessed on weekly routine rounds. Area noted with adherent slough and eschar, surrounding tissue noted with blanchable erythema, dry/flakey skin and fragile. No change to current treatment. Not able to obtain new orders on this date. Wound Bed contains 50 % slough and 50% eschar. Exudate was light serous drainage. Cleansed with generic wound cleaner, application of a debridement autolytic, covered with primary dressing of an antimicrobial and covered with a foam dressing. Additional Care included use of a cushion, foam mattress, heel suspension, protection device with a turning/repositioning program remains in place. Record review also reflected on 09/07/22 a wound assessment was completed by wound care nurse C, measuring Area 2.26 cm, increase in size by 16 %, Length 2.29 cm, increase in size by 1%, Width 1.37 cm, an increase in size of 8 %. Wound assessed on weekly routine rounds. Area noted with adherent slough and eschar, surrounding tissue noted w/blanchable erythema, dry/flakey skin and fragile. No change to current treatment currently. Wound Bed contains slough covering 50% and eschar covering 50%. Exudate remained light and serous in type. Cleansed with generic wound cleaner, application of a debridement autolytic, covered with primary dressing of an antimicrobial and covered with a foam dressing. Additional Care included use of a cushion, foam mattress, heel suspension, protection device with a turning/repositioning program remains in place. Record review of the August/September 2022 TAR (treatment administration record) reflected a treatment, cleanse right lateral malleolus wound with dermaKlenz, pat dry, apply aquacel AG to wound bed and cover with comfort foam adhesive border dressing daily and PRN. Manufactures instructions for use of aquacel AG was for moderate to highly exuding chronic and acute wounds where there is infection or an increased risk of infection. Aquacel AG was designed to stay in place on wound bed for 2-3 days with cautions to not use aquacel AG on dry wounds, not a daily dressing change. Observation on 09/23/22 at 08:35 AM of R44 sleeping in his bed, laying on his right side. Not wearing protective boots or heel suspension to support his ankles. Observation on 09/23/22 at 08:44 AM, Staff getting R44 up out of bed and into his wheelchair for breakfast. Up in wheelchair, feet bangling to floor, no support to feet observed. On 09/23/22 at 10:43 AM, Observation of wound care completed by licensed practical nurse (LPN) Z. Dressing changes completed on Right Lateral Malleolus as ordered, no concerns in technique observed. LPN Z reported This looks red around the wound, so I am going to call the MD. I don't like the looks of this. I saw the dressing change was ordered yesterday; I would assume he (MD) looked at it then. But I will make sure he is notified. During an interview on 09/23/22 at 11:36 AM with wound care nurse C regarding the additional care to prevent further skin break down. I do have on the care plan that he likes to sleep on his right side. We have a heel suspension device, but he doesn't like it. Asked if they had tried any other interventions. No response. I followed up on it as soon as I was notified, it did not happen overnight. We do not use any skin alteration forms for the CNAs to complete when they give showers. Nurses do a weekly skin assessment, and nothing was observed or documented. Skin alteration form completed on 08/18/22 by a CNA who observed the pressure ulcer during care. Continued discussion on the notification to the attending physician and when it was assessed by attending physician. I notified him on 08/18/22 when I was notified, I don't see where he has assessed it yet as of today, 09/23/22. Asked how orders were obtained without assessment from attending physician. We use a standard formulary starting with Aquacel AG then we advanced to Santyl. When Asked about the daily order and manufactures recommendations. Due to the moderate exudate, we use it daily. Review of documentation, it was noted that R44 had light exudate. Record review reflected the last assessment by the attending physician on R44 was on 08/08/22. On 09/23/22 at 11:57 AM, R44 was observed resting in his bed, on his right side, without wearing the heel protectors or suspension, it was noted sitting on the floor in his corner by the TV. During record review on 09/23/22 reflected the task sheets that the CNA's use for care, some areas were marked resolved including turning and repositioning, bed mobility, pressure reducing device, active range of motion and skin observation. Task sheet eliminated the need to address these. Resident #28(R28) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R28 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension(high blood pressure), hearing loss, dementia without behaviors, mood disorder, cerebral vascular accident(stroke), anxiety, depression, +Covid and recent fall with fracture to left lower leg. The MDS reflected R28 had a BIMS (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, locomotion on unit, dressing, toileting, hygiene, bathing and two person assist with transfers. During an observation and interview on 9/20/22 at 2:00 PM, R28 was sitting in reclined broda chair in Dining room facing television with eyes open and ortho boot on left lower leg and appeared thin with moist productive cough noted. R28 appeared calm and not able to answer questions. During an interview on on 9/20/22 at 2:37 PM, R28 was laying in low positioned bed on back with mats on both sides of the bed. During a telephone interview on 9/21/22 at 8:54 AM, R28's Durable Power of Attorney(DPOA) CC reported concerned about R28's recent fall from the bed with left foot fracture when R28 never used feet. DPOA CC reported prior to Covid about 1.5 weeks ago had visited several times each week but had not been able to visit as frequent since Covid outbreak. DPOA CC reported was told by staff that R28's floor mats were not in place at the time of the fall on on 7/18/22. Review of the EMR on 9/21/22 at 9:31 AM, reflected R28 developed a facility acquired suspected deep tissue injury of the left heel related to a medical device that measured 2.82cm by 2.27cm on 8/2/22. Review of the Nurse Progress Note, dated 8/2/2022 at 7:01 a.m., for R28, reflected, Upon residents skin assessment. This nurse noted a suspected deep pressure injury to the L heel, suspected infected ingrown toenail on the L great toe, and suspected pressure injury on the inside of right foot. This nurse covered both deep pressure injuries with a comfort foam border and applied TAO and a Band-Aid to the L great toe . New order to remove surgical boot when in bed and wear when up in chair. Blue offload boots to be in place when in bed. Review of the Wound Evaluation, dated 8/2/22, reflected R28 had a new facility acquired medical device related pressure injury on left heel that measured 2.82 cm by 2.27 cm with 6/10 on pain scale. Review of Nurse Progress note, dated 8/16/22 at 7:54 p.m., reflected R28 had mushy left heel purple and black in color. Review of the Treatment Administration Record, dated 7/1/22 through 8/31/22, for R28, reflected, Fracture boot to LLE at all times, as tolerated Remove Qshift for skin check and PRN. every shift-Start Date-07/26/2022 .Apply Allkare wipes to Bilateral heels at bedtime for soft, mushy heels-Start Date-04/09/2022 2100 . The Record reflected the skin check had been completed on R28 Left lower leg every shift prior to identifying DTI on 8/2/22 that measured 2.82 cm by 2.27 cm. Review of the Provider Notes, between 7/18/22 through current(9/22/22), reflected no provider visits between 8/1/22 and current(9/22/22). R28 DTI identified 8/2/22. During an interview on 9/22/22 at 10:21 AM, Registered Nurse (RN) IC C reported was the facility treatment nurse for one year and was not wound certified. RNIC C reported R28 had current Deep Tissue Injury on left heel that was unstageable. RNIC C reported the facility acquired PU(FAPU) was identified on 8/2/22. RNIC C reported currently treating R28 PU with allkare wipes daily that started 4/9/22 and verified no change in treatments orders since identified 8/2/22. RNIC C reported fallibility did not currently have wound Physician but was working to get one. RNIC C verified three new area on 8/2/22 and reported right not PU, reported spoke with hospice nurse 8/3/22 and communicated and agreed appeared to be bruise. RNIC C reported no follow up documentation to reflected that and should have documented in EMR not just email. RNIC C reported medical device deep tissue injury to left heel was from surgical boot. RNIC C reported on 8/2/22 intervention added to removed surgical boot while in bed an place blue cushion heel protector and verified that intervention had been in place for blue heel protector since 4/2022. RNIC C reported R28 PU is now much larger and 100% escar. RNIC C reported R28 had orders for three times daily skin observations with surgical boot removal and document in TAR. RNIC C reported R28's Deep Tissue Injury likely developed prior to 8/2/22 scheduled weekly skin check and verified TAR reflected skin checks had been completed. RNIC C reported last Wound Evaluation completed 9/22/22 at 7:41 a.m. and wound measured 2.85 cm by 3.15 cm and was covered with 100% eschar(non-viable skin). RNIC C verified no evidence of physician involved with wound between 8/2/22(PU identified) and current with no change in treatment. During an interview on 9/22/22 at 2:34 PM, RNIC C reported Nurse who competed R28 wound assessment on 9/16/22 finished documentation 9/22/22 and documented had communicated with provider and verified no documentation to support R28's wound was unavoidable. RNIC C reported Physician had not seen R28 facility acquired PU. Review of the Nursing Progress Note, dated 7/18/22 at 1:20 a.m., for R28, reflected, 0100 Notified by another Nurse that Res had rolled out of bed and was on the floor. CNA had just finished changing the Res, he left the room to get a blanket and when he returned the Res was on the floor, laying on her right side on the side of the bed facing the door. No injury noted, no bruising, redness, skin tear or open areas noted. Res assisted into bed w/ a 2 staff assist. Norco given at 0108 for s/sx of general discomfort. Neuro-checks initiated, VSS. Res currently resting in bed comfortably. Progress note was created by Registered Nurse (RN) DD. Review of the Nurse Progress Note, dated 7/22/2022 at 11:23 p.m., for R28, reflected, X-Ray results confirm fracture of left distal tibia and left 1st metatarsal. Physician viewed x-ray results and spoke with hospice. Decision was made not to send patient to hospital. Dr increased Norco[pain medication] to BID[two times daily] and orders to be placed for surgical boot. Follow up x-rays in 4-6 months. Spoke with residents son by phone and he is agreeable with plan of care . During an observation and interview on 9/22/22 at 1:20 PM, R28's DPOA CC was at R28's bedside with several other visitors. DPOA CC reported he had received call from the facility early that morning related to R28's recent decline and unresponsive. R28 was lying in bed with eyes closed and washcloth over forehead. During an interview on 9/22/22 at 2:30 PM, Hospice Certified Nurse Aid (CAN) EE reported after each visit she documented on blue communication form in hospice binder. CNA EE verified provided R28 bathing services every Tuesday and Friday and had visit 7/26/22 and 7/29/22 and surgical boot was removed during bath. CNA EE reported nurse [named RN FF] had more detailed records from visits. During a telephone interview on 9/22/22 at 2:55 PM, Hospice RN FF reported assessed R28 on 7/19/22 after the fall and reported R28 was non-verbal and unable to say where pain was initially. RN FF reported R28 was very painful after fall and pain medication added. RN FF reported R28 developed bruising 7/22/22 to left ankle and X Ray was ordered that indicated fracture. RN FF reported delay with boot because facility thought Hospice would provided and boot and they did not and verified boot placed 7/26/22. RN FF reported first made aware of R28 suspected deep tissue injury on the left heel on 8/2/22 reported by facility RN GG. Review of the EMR on 9/23/22 at 8:30 a.m., reflected R28 passed away that morning. During a telephone interview on 9/22/22 at 5:51 pm, Licensed Practical Nurse (LPN) G reported usually worked nights, reported was not present for R28 fall but did care for her after the fall. LPN, G reported difficulty identify area of pain because R28 was non verbal and no signs or symptoms of injury. R28 developed swelling/bruising to left ankle and xray showed fracture. LPN G reported doctor ordered Left Lower Extremity surgical boot to be on at all times with every shift skin assessment. Reported thought that most staff were checking pulses and edema not pressure points. LPN G reported had completed skin assessment shift between 8/1/22 and 8/2/22 and found an area of suspected DTI to left heel that was quite large and stated, did not develop over night. LPN Greported to doctor who gave new order to remove boot while in bed and float heels and use when out of bed. LPN G reported continued to document in Progress Notes related to status of dark purple, mushy left heel. LPN G reported usually day shift completed weekly skin assessment but at times will assist if time allows and that is why she completed skin assessment on 8/1/22 into 8/2/22 shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to communicate with the dialysis center for one (Resident #224) of one reviewed, resulting in the potential for adverse outcomes and unmet care needs. Findings include: Review of the medical record revealed Resident #224 (R224) was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, diabetes, seizures, and end stage renal disease. R224 was dependent on renal dialysis. Review of the Brief Interview for Mental Status (BIMS-cognitive screening tool) dated 9/17/22 revealed R224 scored 15 out of 15 (cognitively intact). On 09/20/22 at 01:25 PM, R224 was observed sitting in a wheelchair in her room. R224 reported the nurse that morning had no idea what to do. R224 reported she had dialysis that morning and the nurse did not have any of the paperwork ready. R224 reported she asked the nurse to write the basic information such as her name and vital signs on a piece of paper. R224 reported on the night of 9/19/22, she was told she would be woken up at 4:00 AM for a 5:30 AM transport time on 9/20/22. R224 reported staff did not wake her up until 5:00 AM, which made her very upset. R224 reported the transport driver had to high tail it to dialysis and that she was five minutes late for her scheduled dialysis time. In a telephone interview on 09/21/22 at 11:53 AM, Certified Nursing Assistant (CNA) R reported there was miscommunication in shift-to-shift report regarding R224's dialysis transport time on 9/20/22. CNA R reported R224's pick up time was supposed to be 5:45 AM, but she was told 6:45 AM. CNA R reported paperwork was not prepared to send to dialysis with R224 and therefore R224's name, room number, and vital signs were written on a piece of paper. In a telephone interview on 09/21/22 at 01:46 PM, RN T reported she was supposed to do R224's dialysis paperwork/communication form on 9/20/22, but she didn't know how. RN T reported R224 was given a piece of paper with her vital signs listed. RN T reported she was not aware of the time R224 was to be transported to dialysis but knows that R224 left at 6:08 AM on 9/20/22. RN T reported the aide also did not know what time R224 was supposed to leave that morning because R224 was a new admission. Review of the Dialysis Communication Form dated 9/20/22 at 12:04 PM revealed the form was locked on 9/21/22 at 8:34 AM. Vital signs listed were all timed for 9:40 AM and 12:39 PM which was R224 was sent out to dialysis. Review of the Nurse's Note dated 9/20/22 at 3:35 PM revealed Resident's dialysis form faxed to [name of dialysis center] to fill out and fax back. Review of the Nurse's Note dated 9/20/22 at 3:54 PM, revealed Received dialysis form filled out . Review of the facility's Dialysis Transportation Policy date 11/21/17 revealed Appropriate paperwork will be sent with the resident to the receiving dialysis center. Facility contact information will also be available on the transporting documents. During a telephone interview on 09/21/22 at 02:42 PM, Dialysis Facility Administrator (DFA) V reported normal communication from the facility would include a communication log with daily issues, full demographics, full set of vitals, medications, allergies, any changes in medications, and recent hospitalizations. DFA V reported on 9/20/22, R224 was sent to the dialysis center with a piece of notebook paper with vitals written. In a telephone interview on 09/21/22 at 02:51 PM, the dialysis center Registered Dietician (RD) W reported she had not spoken to the nursing facility yet. RD W reported R224 was on a 1400 milliliter fluid restriction prior to going to the hospital and will likely need to be on the same fluid restriction. RD W stated R22 has a history of high fluid weight gains. R224's medical record did not mention a fluid restriction. In an interview on 09/21/22 at 03:05 PM, RD D reported she had been off work and R22'4s nutritional assessment had not been completed yet. RD D was not aware if R224 was to be on a fluid restriction and reported she had not spoken with the dialysis center RD yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Physician was assessing and documenting on the full status of a Resident's health regarding facility acquired pressure ulcer for one Resident (#28) reviewed for pressure ulcers. This deficient practice resulted in the potential for lack of coordination of care with the physician. Findings include: Resident #28(R28) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R28 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension(high blood pressure), hearing loss, dementia without behaviors, mood disorder, cerebral vascular accident(stroke), anxiety, depression, +Covid and recent fall with fracture to left lower leg. The MDS reflected R28 had a BIMS (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, locomotion on unit, dressing, toileting, hygiene, bathing and two person assist with transfers. During an observation and interview on 9/20/22 at 2:00 PM, R28 was sitting in reclined broda chair in Dining room facing television with eyes open and ortho boot on left lower leg and appeared thin with moist productive cough noted. R28 appeared calm and not able to answer questions. During a telephone interview on 9/21/22 at 8:54 AM, R28's Durable Power of Attorney(DPOA) CC reported concerned about R28's recent fall from the bed with left foot fracture when R28 never used feet. DPOA CC reported prior to Covid about 1.5 weeks ago had visited several times each week but had not been able to visit as frequent since Covid outbreak. DPOA CC reported was told by staff that R28's floor mats were not in place at the time of the fall on on 7/18/22. Review of the EMR on 9/21/22 at 9:31 AM, reflected R28 developed a facility acquired suspected deep tissue injury of the left heel related to a medical device that measured 2.82cm by 2.27cm on 8/2/22. Review of the Nurse Progress Note, dated 8/2/2022 at 7:01 a.m., for R28, reflected, Upon residents skin assessment. This nurse noted a suspected deep pressure injury to the L heel, suspected infected ingrown toenail on the L great toe, and suspected pressure injury on the inside of right foot. This nurse covered both deep pressure injuries with a comfort foam border and applied TAO and a bandaid to the L great toe . New order to remove surgical boot when in bed and wear when up in chair. Blue offload boots to be in place when in bed. Review of the Wound Evaluation, dated 8/2/22, reflected R28 had a new facility acquired medical device related pressure injury on left heel that measured 2.82 cm by 2.27 cm with 6/10 on pain scale. Review of Nurse Progress note, dated 8/16/22 at 7:54 p.m., reflected R28 had mushy left heel purple and black in color. Review of the Treatment Administration Record, dated 7/1/22 through 8/31/22, for R28, reflected, Fracture boot to LLE at all times, as tolerated Remove Qshift for skin check and PRN. every shift-Start Date-07/26/2022 .Apply Allkare wipes to Bilateral heels at bedtime for soft, mushy heels-Start Date-04/09/2022 2100 . The Record reflected the skin check had been completed on R28 Left lower leg every shift prior to identifying DTI on 8/2/22 that measured 2.82 cm by 2.27 cm. Review of the Provider Notes, between 7/18/22 through current(9/22/22), reflected no provider visits between 8/1/22 and current(9/22/22). R28 DTI identified 8/2/22. During an interview on 9/22/22 at 10:21 AM, Registered Nurse (RN) IC C reported was the facility treatment nurse for one year and was not wound certified. RNIC C reported R28 had current Deep Tissue Injury on left heel that was unstageable. RNIC C reported the facility acquired PU(FAPU) was identified on 8/2/22. RNIC C reported currently treating R28 PU with allkare wipes daily that started 4/9/22 and verified no change in treatments orders since identified 8/2/22. RNIC C reported fallibility did not currently have wound Physician but was working to get one. RNIC C verified three new area on 8/2/22 and reported right not PU, reported spoke with hospice nurse 8/3/22 and communicated and agreed appeared to be bruise. RNIC C reported no follow up documentation to reflected that and should have documented in EMR not just email. RNIC C reported medical device deep tissue injury to left heel was from surgical boot. RNIC C reported on 8/2/22 intervention added to removed surgical boot while in bed an place blue cushion heel protector and verified that intervention had been in place for blue heel protector since 4/2022. RNIC C reported R28 PU is now much larger and 100% eschar. RNIC C reported R28 had orders for three times daily skin observations with surgical boot removal and document in TAR. RNIC C reported R28's Deep Tissue Injury likely developed prior to 8/2/22 scheduled weekly skin check and verified TAR reflected skin checks had been completed. RNIC C reported last Wound Evaluation completed 9/22/22 at 7:41 a.m. and wound measured 2.85 cm by 3.15 cm and was covered with 100% eschar(non-viable skin). RNIC C verified no evidence of physician involved with wound between 8/2/22(PU identified) and current with no change in treatment. During an interview on 9/22/22 at 2:34 PM, RNIC C reported Nurse who competed R28 wound assessment on 9/16/22 finished documentation 9/22/22 and documented had communicated with provider and verified no documentation to support R28's wound was unavoidable. RNIC C reported Physician had not seen R28 facility acquired PU. During an observation and interview on 9/22/22 at 1:20 PM, R28's DPOA CC was at R28's bedside with several other visitors. DPOA CC reported he had received call from the facility early that morning related to R28's recent decline and unresponsive. R28 was lying in bed with eyes closed and washcloth over forehead. During an interview on 9/22/22 at 2:30 PM, Hospice Certified Nurse Aid (CAN) EE reported after each visit she documented on blue communication form in hospice binder. CNA EE verified provided R28 bathing services every Tuesday and Friday and had visit 7/26/22 and 7/29/22 and surgical boot was removed during bath. CNA EE reported nurse [named RN FF] had more detailed records from visits. During a telephone interview on 9/22/22 at 2:55 PM, Hospice RN FF reported assessed R28 on 7/19/22 after the fall on 7/18/22 and reported R28 was non-verbal and unable to say where pain was initially. RN FF reported R28 was very painful after fall and pain medication added. RN FF reported R28 developed bruising 7/22/22 to left ankle and X Ray was ordered that indicated fracture. RN FF reported delay with boot because facility thought Hospice would provided and boot and they did not and verified boot placed 7/26/22. RN FF reported first made aware of R28 suspected deep tissue injury on the left heel on 8/2/22 reported by facility RN GG. Review of the EMR on 9/23/22 at 8:30 a.m., reflected R28 passed away that morning.

Based on observation and interview the facility failed to ensure that all medications were secured in one of three medication rooms observed for secure storage without access to non-licensed staff resulting in the potential for residents to receive legend medications and drug diversion. Findings include: On 9/23/22 at 8:25 am, Licensed Practical Nurse (LPN) G was observed as she prepped medications (med) at the Maple-hall med cart. LPN G had to go to a room behind the Maple-hall nurses station for a missing med. A key and fob were observed hanging on the back wall three to four feet from the end of desk. The storage room was located about two feet further in behind the desk. LPN G used the key to open the storage room, and we went inside. The room had multiple shelves filled with care supplies. On one shelf, about shoulder high. were stored approximately 20-25 bottles of legend medications (both prescription and over-the-counter - prilosec or magnesium etc.). When asked, LPN G said both, not all staff can use the key to get supplies for resident cares. Then, LPG G said, anyone can use the key to get supplies. On 9/23/22 at 8:30 am Certified Nurse Assistant (CNA) J was interviewed and said anyone can use the keys to get supplies. On 9/23/22 at 8:40 am CNA K was interviewed and also said anyone can use the keys to get supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation includes intake MI000128592. Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned and non-care-planned interventions, and 3.) ensure that those interventions were functional and in place in 4 of 6 sampled residents (R19, R28, R30, and R37) reviewed for falls, resulting in repeat falls and R28 unwitnessed fall from elevated bed resulting in left lower leg fracture, deep tissue injury, decline and later death. This deficient practice placed 71 residents at risk for increased likelihood for continued falls, serious injury and/or death. Findings include: Resident #19 (R19) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R19 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included renal disease, anxiety, and depression. The MDS reflected R19 had a BIM (assessment tool) score of 4 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, walking, locomotion on unit, dressing, toileting, hygiene, and bathing. During an observation on 9/22/22 at 8:16 AM, R19 was noted to have signs on door that reflected enhanced precautions. R19's door was open and resident in room appeared to be resting. During an observation and interview on 9/20/22 at 1:47 PM, R19 was standing in the doorway of room independently repeating, help me, help me. R19 reported pants were wet and reported needed assistance. R19 call light was observed on as indicated by light on wall in room(no hall light noted). Staff were noted going in and out of Dining Room about 25 feet from R19 room with no response to R19 shouting, help me or activated call light. Certified Nurse Aide (CNA) AA passed R19 room in hall and reported she was one of two CNA staff working on that hall and left area with out answering R19 call light or looking in room at 1:51 p.m Male CNA staff continued to move residents from Dining Room while R19 continued to be on at 01:53 p.m. At 1:56 p.m. R19 self ambulated back to bed and yelled, Help, that's the same one. (referring to this surveyor). At 2:00 p.m. Infection Control Nurse (IC) C passed R19 room and asked if she needed assistance after R19 yelled for help and entered room. (15 minutes after this surveyor observed R19 yelling for help and call light being on). Review of the facility Resident Matrix, dated 9/20/22, reflected R19 had recent fall with injury. Review of the Nurse Progress Notes, dated 9/9/22 at 6:00 a.m., for R19, reflected, Late Entry: DOCUMENT RELEVANT INFORMATION ABOUT THE RESIDENT:: This nurse was called into resident room by CNA, upon arrival resident was observed lying on her back on the floor beside her bed. On the side of the bed that the window is on. Resident stated she was trying to go to the bathroom. resident assisted to her feet by staff members and walked to the bathroom, vital signs taken and neuro-checks initiated, skin assessed .Created Date : 9/11/2022 04:18:13. Review of the Nurse Progress Note, dated 8/7/2022 at 6:49 p.m., for R19, reflected, Resident in bathroom having self transferred, without her walker and resident has several wash rags on the floor trying to wipe up urine. This nurse assisted resident with clean brief. This nurse washed resident's shoes that had urine on them and cleaned up bathroom. Resident reminded to use her call light. This nurse assisted resident back to bed. Resident had eaten 51-75% of her dinner which consisted of only mashed potatoes. Pleasant. No c/o pain. Review of the facility provided Incident/Accident(I/A) Reports, by the Director of Nursing (DON) B reflected the following falls for R19: -I/A reported dated, 8/31/22 at 5:36 p.m., reflected R19 was observed by staff self ambulating in room and attempted to redirect R19 and R19 tripped over own feet and staff lowered R19 to the ground. The report reflected, Immediate action taken-Description: res. assessed; ROM and VS WNL; physician and guardian notified/ res put into her bed and reminded to use her call light when she needed help . -I/A report dated, 8/15/22 at 4:15 p.m., reflected R19 was observed by floor tech staff slide off bed and land on bottom next to bed with call light on resulting in skin tears to right arm. The report reflected under Immediate Action that R19 was assessed and right arm skin tears were treated with no mention of interventions to prevent further falls with possible injury. Continued review of report reflected notes written on 8/18/22 to prevent further falls staff will check with resident and offer to toilet every two hours while awake. -I/A report, dated 7/18/22 at 8:30 p.m., reflected R19 had an unwitnessed fall in hall near the lobby(entire length of Maple hall, past nurse station and Dining Room from R19 room) while independently ambulation without assist and without 2 wheeled walker. The reported reflected under immediate action that R19 was assessed and physician notified with no mention of interventions to prevent further falls. Continued review of the report reflected notes written on 7/18/22 that included R19 required one person assist with use of 2 wheeled walker and had fall day prior on 7/17/22 after recent admission. The notes reflected physician order to obtain orthostatic blood pressures. -I/A report, 7/17/22 at 2:27 p.m., reflected R19 had an unwitnessed fall in bathroom after staff left R19 alone in bathroom. The reported reflected no immediate actions taken and notes included new intervention to not leave resident alone while in there bathroom. The provided I/A reports did not reflected detailed information for complete and though investigation including when residents last cared for(toileted, observed), if care planned interventions were in place or not, and did not reflect evidence actions were taken to prevent further falls with possible injuries. No I/A Reports were provided for 9/9/22 or 8/7/22. Review of R19 ADL Care Plans, dated 7/14/22, reflected, I have an actual ADL deficit secondary to impaired mobility related to falls in the home setting, syncope, AKI, anxiety, and cognitive impairments .Interventions .AMBULATION: One person limited assist using 2ww[two wheeled walker]. Date Initiated: 07/15/2022 . Continued review of the Care plans reflected, Falls due to recent admission/new environment, syncope, chronic kidney disease, anxiety, mild neurocognitive impairments, impaired mobility, altered mental status, impulsive, wandering behavior, impaired right eye vision, and diarrhea .Revision on 8/5/22 .Do not leave me alone while I am on the toilet. Date Initiated: 07/17/2022. I will wear non-skid footwear for all transfers and walking. Date Initiated: 07/14/2022 .Orthostatic B/P's Date Initiated: 07/14/2022 . Review of the Care Plans revealed no mention of interventions added after 7/18/22. Review of the R19 Fall Assessment Note, dated 9/9/22, reflected, Resident is a [AGE] year old woman admitted on [DATE] for Rehab following hospitalization at [named] Hospital for worsening confusion. She is at risk for falls r/t new environment, syncope, CKD, anxiety, neurocognitive impairment, altered mental status, impulsiveness, wandering behavior, impaired vision in right eye, and diarrhea. She is able to ambulate with assist of one and walker. She requires two persons for toileting with pant management. She had previous falls on 7/17/22 and 7/18/22, 8/15/22, 8/31/22. on 9/9/22 0700 resident observed on the floor by the window side of the bed. She states she was attempting to use the bathroom. Call light was not on and feet were bare. Resident had no injuries and was assisted to the bathroom and then back to bed. She didn't have gripper socks on. Resident was given gripper socks. Her only shoes are crocs at this time. Resident has recently been declared not her own person and a guardian was appointed. Will call DPOA for different shoes. During an interview on 9/21/22 at 4:55 p.m., DON B verified did have I/A reported for 9/9/22 that had been in progress. DON B reported an I/A reported was not completed for R19 8/7/22 fall and should have been. During an interview on 9/23/22 at 1:50 p.m., DON B reported started employment at the facility on 7/18/22. DON B verified was unable to locate R19 orthostatic blood pressures ordered after 7/18/22 fall and reported did not see changed made to the R19 Care Plan after 8/15/22, 8/31/22, or 9/9/22 fall. Resident #28 (R28) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R28 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension(high blood pressure), hearing loss, dementia without behaviors, mood disorder, cerebral vascular accident(stroke), anxiety, depression, +Covid and recent fall with fracture to left lower leg. The MDS reflected R28 had a BIMS (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, locomotion on unit, dressing, toileting, hygiene, bathing and two person assist with transfers. During an observation and interview on 9/20/22 at 2:00 PM, R28 was sitting in reclined broda chair in Dining room facing television with eyes open and ortho boot on left lower leg and appeared thin with moist productive cough noted. R28 appeared calm and not able to answer questions. During an interview on on 9/20/22 at 2:37 PM, R28 was laying in low positioned bed on back with mats on both sides of the bed. During a telephone interview on 9/21/22 at 8:54 AM, R28's Durable Power of Attorney(DPOA) CC reported concerned about R28's recent fall from the bed with left foot fracture when R28 never used feet. DPOA CC reported prior to Covid about 1.5 weeks ago had visited several times each week but had not been able to visit as frequent since Covid outbreak. DPOA CC reported was told by staff that R28's floor mats were not in place at the time of the fall on on 7/18/22. Review of the facility Fall Incident Report, dated 7/18/22 at 12:45 a.m., for R28, reflected, Incident Description Nursing Description: Notified by another Nurse that Res rolled out of bed and was on the floor. She was laying on her right side on the side of the bed closest to the doorway .Resident unable to give description . The Report included CNA HH statement that reflected, CNA had just finished changing Res and walked out to get a blanket for her. When he came back into the room the Res had rolled out of bed and was on the floor. The Report included notes that reflected, She in ext. assist of one for transfers .Will continue winged mattress and bed in lowest position while in it . Continued review of the Report included note, dated 7/22/22, that R28 had X-Ray that showed fractures of the left 1st metatarsal base and left distal fibula fracture. Review of the Electronic Medical Record (EMR), 9/9/2022 at 11:11 a.m., reflected R28 tested positive for Covid. Review of the Nursing Progress Note, dated 7/18/22 at 1:20 a.m., for R28, reflected, 0100 Notified by another Nurse that Res had rolled out of bed and was on the floor. CNA had just finished changing the Res, he left the room to get a blanket and when he returned the Res was on the floor, laying on her right side on the side of the bed facing the door. No injury noted, no bruising, redness, skin tear or open areas noted. Res assisted into bed w/ a 2 staff assist. Norco given at 0108 for s/sx of general discomfort. Neuro-checks initiated, VSS. Res currently resting in bed comfortably. Progress note was created by Registered Nurse (RN) DD. Review of the Nursing Progress Note, dated 7/19/2022 at 6:04 a.m., for R28, reflected, CNA stated that resident was guarding right arm when turned for brief change. Resident stated you broke it as she was turned. Resident scored 6/10 on PAINAD scale. PRN Norco administered at 0502. After administration, resident stopped yelling out and rocking from side to side. Medication effective. Score reassessment 2/10 on PAINAD scale. Review of the Hospice Collaboration Form, dated 7/19/22 at 1:30 p.m., reflected Hospice Home Health Aid visited R28 with plans to provided bath and documented, bath not given due to pain from recent fall . Review of the Nursing Progress Note, dated 7/19/2022 at 2:03 p.m., for R28, reflected, [named] hospice nurse here at this time and notified by this nurse of resident having fall on 7/18/22 at 0045, and that PRN norco has been given twice since then for c/o pain. Resident assessed by hospice nurse at this time, and resident showed s/s of pain with movement of left leg/hip with facial grimacing, and moaning. Hospice nurse spoke with DPOA son [named DPOA CC] to discuss care of resident and he stated that he would like an x-ray of left hip. This nurse then called [named physician] to notify, and order noted for x-ray of left hip 2 view stat. Review of the Nurse Progress Note, dated 7/19/2022 at 9:15 p.m., for R28, reflected, Resident has no c/o pain at this time. Resident does c/o pain when left leg and hip are moved. Neuro checks wnl. This nurse spoke with [named physician] to report left hip XRAY findings: No acute fracture or dislocation .[named physician] advises to also order a 2 view XRAY of the right hip and a 3 view XRAY of the right shoulder. Review of the Nurse Progress Note, dated 7/22/2022 at 2:06 p.m., for R28, reflected, This nurse was called into the residents room to look at left foot and observed it is swollen and bruised. [named physician] in to see patient notified of swelling and bruising of the left ankle and cough and sputum doctor ordered chest xray and ankle and foot xray to be done STAT. Non weight bearing on left leg also ordered. this nurse elevated the foot and put ice pack on it. Review of the Nurse Progress Note, dated 7/22/2022 at 11:23 p.m., for R28, reflected, X-Ray results confirm fracture of left distal tibia and left 1st metatarsal. Physician viewed x-ray results and spoke with hospice. Decision was made not to send patient to hospital. Dr increased Norco[pain medication] to BID[two times daily] and orders to be placed for surgical boot. Follow up x-rays in 4-6 months. Spoke with residents son by phone and he is agreeable with plan of care . During an observation on 9/22/22 at 8:14 AM, R28 was laying in low bed with eyes closed and mats on floor on both sides of bed with washcloth over forehead. During an observation on 9/22/22 at 9:59 AM R28 continued to be in same position in bed, eyes closed, low bed, 2 mats on floor with washcloth on forehead. During an observation and interview on 9/22/22 at 1:20 PM, R28's DPOA CC was at R28's bedside with several other visitors. DPOA CC reported he had received call from the facility early that morning related to R28's recent decline and unresponsive. R28 was lying in bed with eyes closed and washcloth over forehead. During an interview on, 9/22/22 at 1:28 PM, Licensed Practical Nurse (LPN) G reported was not present at the time of R28 fall but worked next day and was responsible for documenting neuron checks and post fall Progress Note. LPN G reported facility policy was to document every shift for 72 hours after a fall. During an interview on 9/22/22 at 2:30 PM, Hospice Certified Nurse Aid (CAN) EE reported after each visit she documented on blue communication form in hospice binder. CNA EE verified provided R28 bathing services every Tuesday and Friday and had visit 7/26/22 and 7/29/22 and surgical boot was removed during bath. CNA EE reported nurse [named RN FF] had more detailed records from visits. During a telephone interview on 9/22/22 at 2:55 PM, Hospice RN FF reported assessed R28 on 7/19/22 after the fall and reported R28 was non-verbal and unable to say where pain was initially. RN FF reported R28 was very painful after fall and pain medication added. RN FF reported R28 developed bruising 7/22/22 to left ankle and X Ray was ordered that indicated fracture. RN FF reported delay with boot because facility thought Hospice would provided and boot and they did not and verified boot placed 7/26/22. RN FF reported first made aware of R28 suspected deep tissue injury on the left heel on 8/2/22 reported by facility RN GG. Review of the Fall Care Plan, dated 10/12/18, for R28, reflected, I am at risk for falls due to history of falls, severe cognitive impairments related to dementia and history of CVAs, incontinence, significant osteoporosis , osteopenia. I have poor safety awareness and may lean over in my chair or scootch in my bed towards the edge. I am receiving hospice services and an expected decline is expected .Interventions .Bed in low position when in bed. Date Initiated: 07/27/2022 .BILATERAL FLOOR MATS to be in place while in bed. Date Initiated: 06/02/2021 . Review of the EMR on 9/23/22 at 8:30 a.m., reflected R28 passed away that morning. During a telephone interview on 9/23/22 at 12:19 PM, RN L reported was present at the time of R28 fall on 7/18/22. RN L reported CNA HH was providing care and stepped out of R28 room to get a blanket and returned and R28 had rolled out of bed. RN L reported arrived to R28 room and observed R28 laying directly on the floor on her left side with no floor mat in place and bed was positioned at waist level. RN L reported was not R28 nurse at that time but was in the area charting when she was alerted of R28 fall. During an interview on 9/23/22 at 1:15pm, uncertified Nurse Assistant ([NAME]) II reported worked 7/18/22 day shift after R28 fall. [NAME] II reported was told R28 had fall from bed but not provided details about the fall but reported received reinforcement education that fall mat should be in place of residents are in bed and bed should be in lowest position should be standard practice. During a telephone interview on 9/23/22 at 1:20 PM, RN DD reported did complete R28's fall Incident Report on 7/18/22 at 12:45 a.m. and reported was unsure how R28 was transferred off the floor. RN DD reported was not present at time of fall because she was also working on another hall at that time. RN DD reported had spoke with CNA HH who reported had left R28's room after providing care to get blanket and R28 was on the floor when he returned. RN DD reported did not recall if she asked if fall mats were in place or what the position of bed was. RN DD reported thought manager did investigation. During an interview on 9/23/22 at 1:50 p.m., Director of Nursing (DON) B reported started employment at the facility on 7/18/22. DON B reported aware that falls were an issue and had noticed immediate actions taken on I/A reports were resident assessments and should reflect what was done prevent further falls. DON B verified resident assessments do not not prevent falls. DON B reported that now either herself or Administrator A review all I/A reports prior to being locked. During a telephone interview on 9/23/22 at 2:25 PM, CNA HH reported left R28 room to get a blanket after care and heard R28 make sound in room, returned to room, and found R28 on the floor moaning. CNA HH reported RN DD was nurse at time but was wrap nurse and was on the other hall at the time of the fall. CNA HH reported RN L assisted him to get R28 back to bed and reported was unable to recall if fall mats were in place at the time of the fall and reported R28 should have been a two person assist. During an interview on 9/23/22 at 2:56 PM, DON B reported would expect staff to include as many details as possible on fall reports including if ordered care planned interventions were in place or not at the time of the fall. Resident #30 (R30) A review of the Minimum Data Set (MDS - resident assessment), dated 8/1/22, reflected R30 was admitted to the facility on [DATE] with diagnoses that included history of breast and lung cancer, irritable bowel syndrome with diarrhea, vascular dementia with behaviors, psychosis and moderate cognitive impairment, stroke with right hemiplegia (difficulty moving extremities, especially right arm) and hemiparesis (difficulty feeling extremities), History of thoracic vertebrae fracture, depression, anxiety, osteoarthritis, congestive heart failure and seizures. A review of the Activities of Daily Living (ADLs) plan of care reflected R30 required limited assist of one staff person with four-wheel walker for ambulation and transfers, and one staff person extensive assist for showers. Care plan interventions for R30 about falls: dated 3/2/22 were assess and treat my pain, non-skid footwear for all transfers and walking, labs/x-rays, medication reviewed by pharmacist, orient to surroundings, orthostatic blood pressures and therapy referral as needed. Dated 4/30/22 resident re-educated on use of call light to request assistance for transferring. Dated 5/2/22 was resident re-educated to ensure her wheelchair brakes are locked before any transfer in or out of her chair. A review of the facility policy titled Fall Reduction Program, last revised on 9/25/16, reflected: Procedure 2. Implement and indicate individualized interventions on Care Plan/[NAME]. 3. If fall occurs Charge Nurse to complete the following .Immediate interventions as identified by physical assessment and environmental observation .3.1 Initiate safety interventions and update care plan as applicable .3.3 IDT [interdepartmental team] to review each incident to complete root cause analysis .3.4.3. Identify any additional interventions in the Care Plan/[NAME]. A review of fall investigation reports reflected R30 had several falls. Each fall, intervention and if the care plan was updated during a discussion with Director of Nurses (DON) B on 9/23/22 at 1:25 pm as follows: On 8/2/22 at 5:30 am R30 raised the head of her bed, attempted to get into her wheelchair and missed it. There were no injuries. The intervention was to demonstrate call light to use to call for help. This intervention was already entered on 4/30/22 and the date was not updated. DON B did not see this on the care plan since this fall. On 8/8/22 at 7:42 pm R30 was found sitting on the floor of her bathroom. The indwelling catheter was removed that day. There were no injuries. Repeated interventions were demonstrate call light and call staff for help. A new intervention was therapy to assess and treat for toilet transfers which was already in the care plan without an updated date. DON B said no new intervention were added to the care plan until later. On 8/17/22 supervise on toilet was added. On 8/21/22 at 1:00 pm R30 was found on the bathroom floor after attempting self-transfer to the wheelchair. R30 said she was waiting for her aide to get additional help to get off the toilet. There were no injuries. The interventions were turn on call light, maybe yell for help and wait for help/supervision which were already on the care plan. DON B said there were no new interventions. On 9/7/22 at 3:53 pm R30 was yelling for help and observed face down on the bathroom floor. R30 sustained a small skin tear on the forehead. The intervention to supervise on toilet was added, and DON B agreed and said the aide was fired after multiple warnings about supervision to prevent falls for R30. Resident #37 (R37) A review of the MDS, dated [DATE], reflected R37 was admitted to the facility on [DATE] with diagnoses that included moderate cognitive impairment, stroke from a blocked brain artery with right-sided hemiplegia (difficulty moving extremities, especially right arm) and hemiparesis (difficulty feeling extremities), osteoarthritis, history of falls, and aseptic necrosis of the right resulting in hip replacement surgery, acute kidney failure, depression, anxiety, insomnia, dysphagia (difficulty swallowing), history of pneumonia, constipation, flexion (bending) contractures (frozen joint) of both knees, tremors and spasticity of right lower leg, vascular dementia and weakness. A review of the ADL plan of care reflected R37 required the use of a standing lift with two staff assist for toileting and transfers. R37 had a high-back, reclining wheelchair with right arm trough and a reclining lumbar support cushion but could not move in the wheelchair. They require one staff assist to push them. The drag lift is used to lift someone from the bed, chair, or floor by lifting or supporting them under the armpits. This lift strains and damages the cervical and other nerves, tendons, ligaments, and skin, and can cause pain and the inability to use the arm/hand. Drag lifts should never be used. On 9/21/22 at 8:55 am, R37 was observed in his wheelchair in his room. Certified Nurse Assistant (CNA) I repositioned R37 higher in the wheelchair by pulling them up, using their hands in R37's armpits, from behind. When asked, R37 said they were alone at home when they fell on their right side and laid there quite a while. Because of this fall, R37 stated their right arm was almost useless, but My left arm has full mobility. On 9/23/22 at 12:25 PM, Occupational Therapist Assistant (OTC) O demonstrated how to properly lift a resident like R37. They said the axilla was never used due to potential nerve damage. On 9/23/22 at 12:35 PM, CNA P was interviewed. When asked about transferring a resident out of a chair, CNA P said they would always start with a gait belt and would not lift by the armpits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to establish and maintain an infection prevention, monitoring and control program while residents are in quarantine with Covid, resulting the potential for the spread of microorganisms when staff did not wear personal protective equipment while assisting residents. Staff did not perform hand hygiene before or after care, did not change out gowns, mask or clean goggles before leaving the residents room, resulting in the potential for the spread of infections to (R35, R39, R49, R56, R224) and up to 71 residents who resided at the facility. During observation on 09/23/22 at 08:50 AM, Staff were observed entering and exiting the residents' rooms on quarantine without wiping goggles off or changing out mask. During an interview on 09/23/22 at 08:55 AM with unit manager AA discussion regarding residents coming off quarantine. All staff should be wiping off goggles after exiting rooms. No observation of this task completed between 6 staff members on C hall. During an interview on 09/22/22 at 10:07 AM with Certified Nursing Assistant (CNA) BB regarding the screening process. After screen in, we have a report we go over between shift change and we go room to room and discuss every resident. Observation on 09/22/22 at 10:26 AM of CNA CC not wearing any protective eye wear. Observation on 09/22/22 at 10:34 AM of vital sign machine not being cleansed before or after use, taking it into a resident's room, from hallway into RM [ROOM NUMBER]. Staff walked out of room holding dirty gown in hand and throw away in hallway linen container, not the dirty linen container in the room on two separate occasions within 5 minutes of each other. During an interview on 09/22/22 at 02:02 PM with Infection Control, Infection Prevention (ICIP) C My first thing is to grab the sign in log for staff and visitors, did anyone screen positive, I instruct staff to contact self or charge nurse if they have symptoms. I will do a round to check in and do walk throughs. For infections, we are tracking them on the line list, try to discuss during the morning meetings, same with antibiotics, making sure they meet criteria. Tuesdays and Fridays are staff Covid testing days. Resident's get tested as needed. ICIP was asked about the visitors check in process. Visitors, it's a team approach, nobody is sitting there watching, receptionist is close by, Director of Nursing office is up there, Administrator's office is right there, and human resources is watching. Visitors wear KN95 or any face covering.Continued conversation regarding who watches the staff for compliance. I do multiple rounds, watch hand hygiene, make sure they have personal protective equipment (PPE), watch them use the equipment, touching face mask and washing with hand sanitizer. Discussion on who wears what mask. Fully vaccinated staff wear the KN95, unvaccinated staff wear N95, also reporting Staff are to change out mask when they enter and exit the room, goggles are to be wiped with purple top cleaner, along with any equipment used. On 09/23/22 at 10:19 AM, observation of laundry staff emptying the dirty linen from the quarantined residents' rooms, wearing one glove on right hand, left hand bare, wearing mask and goggles, no gown to protect scrubs from contaminated gowns. Large container for dirty gowns had a bio-hazard sticker on it. Resident #224 (R224) Review of the Physician's Order dated 9/17/22 revealed Transmission Based Precautions includes: Droplet, contact, airborne precautions. In addition you must wear an N-95/KN95 in the patients room. On 9/20/22 at 1:25 PM, R224's door was observed with signage that indicated transmission-based precautions and enhanced precautions. The signage indicated the use of gown, gloves, face shield, and mask. R224 reported she was a new admission, had received covid vaccines, but not the most recent booster. During the interview, a staff member walked into R224's room wearing only a KN95 mask and a face shield. The staff member pulled down their mask and asked R224 if she had a bowel movement. When asked about the transmission-based precautions, R224 reported staff started wearing full PPE the day before, on 9/19/22. Upon exiting the room, two staff members were observed speaking with Infection Preventionist (IP) C regarding clarification on the transmission-based precaution PPE requirements. Resident #56 (R56) Review of the medical record revealed R56 was admitted to the facility on [DATE] and tested positive for COVID-19 on 9/16/22. Review of the Physician's Order dated 9/16/22 revealed Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room. On 9/20/22 at 2:17 PM, Maintenance Director X was observed donning PPE to enter R56's room. Maintenance Director X donned the gown with the opening in the front, exposing clothing. Resident #35 (R35) Review of the medical record revealed R35 was admitted to the facility on [DATE] and tested positive for COVID-19 on 9/16/22. Review of the Physician's Order dated 9/16/22 revealed Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room. On 9/20/22 at 2:21 PM, Activities Director (AD) Y was observed donning PPE to enter R35's room. AD Y wore a KN95 into the room. Upon exiting the room, AD Y did not disinfect the eye protection or change masks. AD Y then left the unit. Resident #49 (R49) Review of the medical record revealed R49 was admitted to the facility on [DATE] and tested positive for COVID-19 on 9/11/22. Review of the Physician's Order dated 9/11/22 revealed Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room. Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility on [DATE] and tested positive for COVID-19 on 9/14/22. Review of the Physician's Order dated 9/14/22 revealed Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room. On 9/20/22 at 4:09 PM, a staff member exited R49's room wearing a KN95 and goggles. The staff member sanitized their hands, prepared beverages, donned a new gown and gloves, and entered R56's room. The staff member did not change their mask or disinfect their goggles. The staff member exited R56's room, wearing a KN95 and goggles. The staff member sanitized their hands, prepared another beverage, donned a new gown and gloves, and entered R39's room without disinfecting their goggles or changing into a N95. In an interview on 9/21/22 at 3:51 PM IP C reported their current PPE supply did not allow for them to dispose of a mask after each room. IP C reported goggles and face shields should be disinfected between each transmission-based precaution room.