This citatoin pertains to intake #MI00152841. Based on interview, and record review, the facility failed to ensure a resident was free from significant medication errors for one (R803) of four residents reviewed for medication administration, resulting in a significant change in condition and hospitalization when R803 received R801's medications. Findings include: Review of a complaint reported to the State Agency included allegations that a male resident received a heavy dose of his roommate's medication during the midnight shift and was sent to the hospital the next morning, foaming at the mouth. Review of R803's clinical record revealed the resident was admitted into the facility on 4/23/25 and discharged to the hospital on 4/26/25. As of this review, R803 had not returned to the facility. Diagnoses included: ischemic cardiomyopathy, permanent atrial fibrillation, ASHD (Atheriosclerotic Heart Disease) of native coronary artery without angina pectoris, CHF(congestive heart failure) pulmonary hypertension, type 2 DM (Diabetes Mellitis) with unspecified complications, nondisplaced fracture of greater trochanter of left femur, acute kidney failure, presence of coronary angioplasty implant and graft, and bradycardia. Review of the progress notes revealed following the administration of another resident's medications, R803 had a significant change in condition and changes in vital signs in which the resident was transferred to the hospital for further treatment. The progress notes included: An entry on 4/26/25 at 12:10 AM by Licensed Practical Nurse (LPN) 'G' read, Gave res (resident) wrong medication. Realized immediately when given. Notified Dr [Name of Nurse Practitioner/NP 'D'], Nurse on call DON (Director of Nursing) with no reply .No adverse reaction at this time.No change mental status.VS (Vital Signs) within normal limits.B/p (Blood Pressure) 132/68 hr (Heart Rate) 78 resp (respirations) 18 bs (blood sugar) 172 temp (temperature) 98.4.No s/s (signs/symptoms) of distress or discomfort at this time. An entry on 4/26/25 at 6:26 AM by LPN 'H' read, Resident got wrong medication last shift. In bed very lethargic. HOB (Head of Bed) elevated. 2400 (12:00 AM) (BP) 134/ 82 (O2) 96% .(Resp) 16 (Blood Sugar Level) AC 190. 0200 (2:00 AM) .(O2)93% (Resp) 18 (BP) 110/52 (HR) 64 (Blood Sugar Level) AC 136. Remains lethargic. Breathing unlabored. 0300 (3:00 AM) .(O2) 93% (Resp) 18 (BP) 81/55 (HR) 79 (Blood Sugar Level) AC 142 Continues to open eyes and that is about it. Chat easy sent to doctor about lethargic and BP drop. No new orders. 0400 (4:00 AM) .(O2) 92% (Resp) 18 (BP) 109/47 (HR) 93 (Blood Sugar Level) AC 134. HR. ranging from 79 to 100. Continues to snore and open when touched. 0430 (4:30 AM) chat easy sent with new VS (Vital Signs) and changes. No new orders. 0600 (6:00 AM) .(O2) 93% (Resp) 18 (BP) 122/61 (HR) 82 (Blood Sugar Level) AC 151. Did open mouth for TSH RX (Thyroid Medication). Continues to bed lethargic. 0625 (6:25 AM) chat easy sent and updated doctor. Improved BP and HR more stable. An entry created on 4/26/25 at 6:55 AM by Nurse Practitioner (NP 'D') for 4/25/25 documented an asynchronous - telehealth note that read, .Nurse called and report that she gave the resident was given wrong medication. These are medication that was given to the resident that does not belong to him: Divalproex Sodium 250mg (Milligrams - an anticonvulsant medication), levetiracetam 1000mg (an anticonvulsant medication), Metformin 1500mg (a diabetic medication), Clonazepam (a benzodiazepine medication), and cloZAPine Oral Tablet 200 MG (an antipsychotic medication), Lacosamide Oral Tablet 50 MG (an anticonvulsant medication). Resident doing well and Vital signs: BP (Blood Pressure) 128/62, P (Pulse) 86, O2 sat (Oxygen Saturation) 96% RA (Room Air), BS (Blood Sugar) 123, 20. Advise nurse not to give resident his Trazodone but can give Xarelto and Atorvastatin. Advise nurse to monitor vitals q (every) 2 hours and report any medical issue. Will update rounding provider. (There was no further documentation after this entry from the rounding provider and this entry did not identify/address the significant BP results reported by nursing staff.) An entry on 4/26/25 at 9:07 AM by Registered Nurse (RN 'I') read, Resident being monitored after medication error last night. Resident unresponsive to stimuli, and has increased secretions/ gurgling in throat. On call provider notified of changes and agreed to send to ER (Emergency Room) for further evaluation. A late entry on 4/28/25 at 7:49 AM for 4/28/25 at 7:40 AM by Nurse 'J' (Nurse on-call on 4/25/25) read, Late entry for 4/25/25: Contacted by floor nurse That <sic> she had given medications to this patient in error. Instructed to contact the on-call provider for further orders. This writer made DON aware and was instructed to have the floor follow up with on call provider. See floor nurse's note and on call provider's note for further information. On 5/28/25 at 11:25 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked to provide any documentation and facility investigation regarding R803's medication error incident. On 5/28/25 at 11:35 AM, a phone interview was conducted with LPN 'G'. When asked to recall the events regarding R803's medication error, LPN 'G' reported they worked contingent but had been working at the facility for 21 years as a manager. They reported they had been assigned to the south unit, which was a memory care unit. They also had to take rooms that were on the north unit and a few rooms on the Tulip wing (outside of the secured unit). LPN 'G' recalled R803 was a newer admission to the facility and they had gone to the room with R801's (roommate of R803) medications in a cup in their hands and R801 was getting up so they tried to put him back into the bed. While doing that, R803 was also getting up and they set the medication cup down on R803's tray table and when they got both residents back into bed, LPN 'G' gave R803 his medications. I had to set the medications down to get them back in bed and accidentally gave R803 the medications for R801. As soon as they did it they knew and immediately called the physician and the Assistant Director of Nursing (ADON). LPN 'G' reported following this incident, the ADON was working with them about completing paperwork and training, but due to family emergency the ADON had been off since then. LPN 'G' reported the midnight nurse (LPN 'H') was there and reported it, the on-call said to monitor and call him back at 4:00 AM. LPN 'G' reported he seemed fine throughout the night and think when first shift came in they heard he was lethargic. LPN 'G' further reported the incident occurred on Friday and they were in the facility that Monday with the ADON. LPN 'G' also reported they were sure R803 received all of R801 they had prepared since they were all crushed in the medicine cup. On 5/28/25 at 12:35 PM, an interview was conducted with the DON. When asked about the medication error incident, the DON reported the facility had identified a Past Non-Compliance (PNC) regarding this incident and would provide documentation for review. The DON reported since the incident, the facility now looked at the 24 hour reports everyday and if the floor nurses reported medication errors, they were to report it to them directly and each medication error was looked into. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Element 1: Resident [Name of R803] is no longer in the facility. Element 2: The Director of Nursing/designee reviewed the last 7 days of Progress Notes for changes in condition being documented appropriately and timely and with proper notification. Any concerns were immediately addressed. Completed on 5/9/2025. Element 3: The Medication Administration policy and the Provision of Quality of Care policy was reviewed by the QAPI (Quality Assurance Performance Improvement) committed and deemed appropriate on 5/2/2025. The DON/Designee has re-educated all current nursing staff on Medication Administration policy by 5/14/225. Any current nursing staff member not re-educated by 5/14/2025 will be re-educated prior to their next scheduled shift. The DON/Designee has re-educated the IDT (Interdisciplinary) team on the Provision of Quality of Care policy by 5/19/2025. Any IDT team member or rehab staff member not re-educated prior to 5/19/2025, will be re-educated prior to their next working shift. IDT team will review in clinical morning meeting daily, Monday - Friday, to review the 24 Hour Report and identify all changes in condition for timely follow up. During the day, the Unit Managers will view medication records to validate accuracy. Element 4: The DON/Designee will audit all changes in condition daily, Monday - Friday, to ensure appropriate interventions are placed timely. The DON/Designee will audit 10 medication records twice a week to ensure accuracy. Audits will continue daily x4 weeks then weekly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The Director of Nursing is responsible to maintain compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #'s MI00146852 and MI00146901. Base on observation, interview and record review, the facility failed to ensure a timely investigation of a fall, complete a safe transfer, provide urinary assistance per the plan of care and provide appropriate supervision and interventions to prevent falls for two residents (R35 and R119) resulting in R119 sustaining an acute subcapital left femoral neck fracture. Findings include: On 9/16/24 a concern submitted to the State Agency was reviewed which alleged R119 had a fall with a fracture and the facility delayed in documenting and assessing R119 for injuries. On 9/17/24 the medical record for R119 was reviewed and revealed the following: R119 was initially admitted to the facility on [DATE] and had diagnoses including Difficulty in walking, Restlessness and Agitation and Chronic obstructive pulmonary disease. A review of R119's MDS (minimum data set) with an ARD (assessment reference date) of 6/9/24 revealed R119 needed assistance from facility staff with most of their activities of daily living. R119's BIMS score (brief interview for mental status) was three, indicating severely impaired cognition. A review of R119's comprehensive plan of care revealed the following: Focus-Resident is at risk for falls/injury related to: cognitive deficits, history of falling, visual deficits, takes psychotropic medications, and weakness Bed Modification: Patient prefers his bed against the wall. Date Initiated: 10/04/2023 .Interventions:-Frequent rounding while in resident room. Date Initiated: 09/09/2024 .Focus-Resident has an ADL (activity of daily living) self-care performance deficit related to: cognitive deficits, visual deficits, weakness, and difficulty in walking Date Initiated: 10/04/2023 .Interventions-TRANSFERS: 2 person assist. Date Initiated: 10/04/2023 . A review of R119's progress notes revealed the following: 9/3/2024 .Date of Service: 9/3/2024. Visit Type: Acute. Chief Complaint: Pain left hip. History of present illnesses: General: [AGE] year-old male with past medical history significant for diabetes dementia A. fib (Atrial fibrillation) pneumonia. Pt (Patient) is seen today per nursing requested for pain on the left hip. There was no reported of fall. Per nursing pt started to c/o (complained of) pain this morning. Pt alert but confuse, baseline, did not remember of fall .Assessment and Plans-Pain in left hip: Ordered X-ray left hip, right hip, lumbar, and left femur. Ordered tramadol 50 mg (milligrams) q6 hrs prn (every six hours as needed) for 1 wk (week). continue to monitor . 9/3/2024-Nurses' Notes: Writer called to resident room for evaluation related to resident indicating left leg pain and declining to get out of bed. Resident observed in bed, alert to baseline. C/O left upper leg pain and left hip pain. Resident stated to writer I fell. Resident assessed, unable to lift left leg off bed, left hip and upper leg painful to palpation, resident with facial grimacing, unable to determine any leg shortening or rotation, resident unable to lay flat due to increase in pain . A SBAR (Situation, Background, Assessment, Recommendation) Communication Form with an effective date of 9/3/24 that was completed by R119's day shift nurse on 9/3/24 at 09:34 revealed the following: Request 4. Nursing Notes: VS (vital signs) and neuros (neurocheck) unremarkable and baseline. Writer attempted medication administration, resident declined medication, which is unusual for resident. When resident asked why he declined medication, he was unable to answer. A&O (alert and orientated) to self and baseline, moments of confusion, poor historian, usually follows commands. When asked if resident has pain, he initially declined pain. When resident was asked to sit up, he verbalized 'give me a hand.' When assistance was given, resident shouted out in pain. Assessment revealed left hip and left lower back pain. Resident unable to raise left leg off bed. Any movement of hip caused pain, but resident could not quantify pain, although using Wong-Baker it was 0 at rest, and 9/10 with movement. Declined to be rolled or changed. Left hip was externally rotated, it appeared shortened compared to right leg, although resident was poorly positioned in bed during assessment, then resident declined to reposition self or allower <sic> staff to reposition, and declined further assessment. Declined breakfast, which is unusual for resident since he baseline requests more that one breakfast and eats 100% of his breakfast. No bruising at left hip site. Verbalized he did not fall, verbalized he did not hit head. Dx. (diagnosis) Dementia, Provider [name of medical provider] on unit for evaluation. Ordered STAT hip and lumbar x-ray. DPOA daughter [name of DPOA] verbalized she instead wanted resident sent to [local hospital] immediately 9/7/2024-Nursing Evaluation Summary: Resident came back from [local hospital] via EMS (ambulance) at 1600. Residents principal problem is a closed displaced fracture of left femoral neck. Incision is 20 1/2 inches long with dressing intact and dry. Follow up with ortho (orthopedic) in 1 week to have post-op incision checked. Foley catheter in place with orders for follow up with urology in two d/t (due to) failing voiding trial Resident only complains of pain upon movement. Respiration equal and unlabored 9/9/2024 .Progress Notes-Date of Service: 9/9/2024 .History of present illness-General: [AGE] year-old male with past medical history significant for diabetes dementia A. fib pneumonia. Pt is seen today for re-admission. Pt sent to hospital for left hip pain. Pt found to have subcapital left femoral neck fracture. Pt underwent left hip hemiarthroplasty .Assessment and Plans- Risk of Complications and/or Morbidity or Mortality of Patient Management: moderate .Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing: PT/OT, monitor site for s/s of infection(drainage, edema, redness) F/u (follow-up) with orthopedic sx (surgery) as recommended . A review of the facility investigation and statements from staff pertaining to R119's fractured femur identified on 9/3/24 revealed the following: A statement from CNA (Certified Nursing Assistant) O (CNA O) on 9/5/24 who was identified as one of the CNA's who worked the midnight shift from 9/2/24 through 9/3/24 revealed the following: I worked on South. I work 11pm to 7am. I worked with [CNA S] and [Nurse R]. [R119] was sleeping when I arrived, and stayed asleep. I went on lunch around 04:10. I found him on the floor, [CNA S] was on lunch. He was behind bedroom door, hand was sticking out from the door. He was on his left side, his head was in the corner. I don't recall if he said anything to me. I called for [Nurse R] and said '[R119]'s on the floor'. We two person lifted him onto the bed, [R119] then said he was trying to go to the bathroom. He was complaining of left leg pain. The Nurse educated him, she didn't see any injury. The Nurse and I attempted to assist him to the bathroom. He couldn't stand, I couldn't find a urinal so I grabbed a cylinder. [CNA S] entered room right after he was done urinating. When he was on the floor, his bed sheet was wrapped around his feet. Until about 0600 he kept yelling for help, we kept checking on him. I texted [CNA S] at 03:40 that a resident fell . A statement from Nurse R on 9/5/24 who was identified as the Nurse assigned to R119 on the midnight shift from 9/2/24 through 9/3/24 revealed the following: I got to work around 2:30pm, I was on South. [R119] as his normal self. He gets meds early afternoon, and evening meds. I'm not sure when he went to bed. Wandered into the hall around 11pm. I redirected him back to his room. I didn't see him get up at any other point during the night. I checked on his roommate around 1am, [R119] was sleeping. I was not notified he was having any pain. When I gave report to day shift, I;I'm pretty sure he was still in his room A statement from CNA S on 9/5/24 who was identified as another CNA assigned to R119's unit on the midnight shift from 9/2/23 through 9/3/24 revealed the following: Worked on South. [R119] went to bed around 0200 on 9/3. I went to lunch around 03:15, returned to unit quarter to 4. I go outside on my lunch. [CNA O] texted me around 3:30 that he fell. I returned to the unit, [CNA O] and [Nurse R] were assisting [R119] with the urinal. He never asks for help. Kept going into his room to check on him, he was talking and wanting 'the guys' to help him fix something. I work 7pm-7am . A second statement from CNA O on 9/10/24 recorded by the Assistant Administrator during their final interviews revealed the following: During an interview with employee [CNA O] regarding a resident investigation, employee stated that when she found the resident on the floor, she immediately began texting her counterpart [CNA S] who was on break at the time. Writer asked why her immediate thought was to text her counterpart and not assist the resident, she stated that she always let's her partners know when something happens to a resident. Writer then asked what happened. [CNA O] stated she went and got her Nurse [Nurse R] in the common area to assess the fall. She stated resident was having a hard time walking to the bathroom, so they stood him to use the urinal. Writer then asked [CNA O] if the resident was showing signs of pain and distress and having a hard time sanding <sic> which she stated that she noticed, why would she make him stand to use a urinal since a urinal can be used lying or sitting. She stated, 'Oh yeah, I guess you're right.' She stated that they proceeded to help him use the bathroom in the urinal or cylinder. [CNA O] also stated that resident continued to need two people to assist him throughout the night and yelled out in pain. When asked why she didn't report it to another Nurse if she didn't feel confident that her Nurse had reported the fall or was doing the 'right thing' on behalf of the resident, she stated she didn't know she could and didn't know that CNA's did fall charting or behavioral charting. On 9/18/24 at approximately 11:05 a.m., the Director of Nursing (DON) was queried regarding their investigation of R119's fall during the early morning hours on 9/3/24. The DON stated that they were notified by the day shift Nurse T in the morning of 9/3/24 that R119 had been presenting with pain in their left leg. The DON indicated they assessed R119 at that time and then asked Nurse T to call the medical provider and get an order for an X-ray. When Nurse T notified the family of the change in condition they requested him to be sent out to hospital instead of having the in-house X-ray completed. The DON indicated that through their investigation, it was revealed that CNA O never informed Nurse R of R119's fall and had assisted R119 back into bed by themselves which was against facility policy. The DON indicated that CNA O should have had Nurse R assess R119 for any injury and then together they could have transferred them with the mechanical lift back into the bed. The DON also reported that after the fall, CNA O transferred R119 into a standing position to use a urinal without getting anyone to assist them and without Nurse R having had a chance to assess them. The DON reported that CNA O had multiple inconsistent reports of the incident and that they had filled out 15 minute check documentation for monitoring R119 that night and that no fall was indicated on the checks when CNA O had found R119 on the floor. The DON indicated that disciplinary action was issued to all three staff members including CNA O, CNA S and Nurse R and that Nurse R was disciplined for not following facility policy on providing supervision to R119 at least every two hours and checking on them. On 9/18/24 at approximately 4:10 p.m., Nurse R was queried regarding R119's fall during the midnight shift from 9/2 through 9/3/24. Nurse R reported that neither CNA O or CNA S had informed them that R119 had fallen in their room. Nurse R indicated they were never provided an opportunity to assess R119 for injury and that they were never consulted when CNA O transferred them back to bed by themselves. Nurse R was queired regarding assisting CNA O with R119 using the urinal later that night and they indicated they did not do that, and were unaware of any concerns regarding R119 that night. Nurse R reported that it was very unfortunate of what occurred, but that they knew nothing about R119 falling. On 9/18/24 a review of the disciplinary action forms titled Performance Improvement Form that were all dated for 9/9/24 for Nurse R, CNA O and CNA S revealed the following: Employee Name [Nurse R] .Reason for counseling/corrective action: Employee failed to check on resident every two hours per policy . Employee Name: [CNA S] .Reason for counseling/corrective action: Employee failed to report resident change to supervisor regarding resident complaint of extreme pain after unreported fall resulting in major injury to the resident . Employee Name: [CNA O] .Reason for counseling/corrective action: Failure to comply with 6.1 in employee handbook (1. violating resident right, failing to report to supervisor, 6. Falsifying documentation, 22. disruptive behavior) and 7.2 accidents to residents, 'if you suspect serious injury, do not move resident.' Employee failed to notify supervisor of resident change, didn't document resident experienced change in condition. Employee did not notify supervisor of resident fall that resulted in major injury, employee improperly assisted resident off the floor .Counseling sessions/corrective actions: Termination of employment . R35 On 9/16/24 at approximately 11:10 AM, R35 was observed lying in bed. The resident had bruising around their right eye as well as wraps around both their lower and upper right arm. The resident was alert but could not answer questions regarding the observation. A review of the R35's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Epilepsy, vascular dementia, and traumatic brain injury. A review of R35's MDS noted the resident had a BIMS (8/30/24) score of 0/15 (severely impaired cognition). The resident was noted to be incompetent to make their own decisions and had a court appointed guardian. Continued review of R35's clinical record and Incident/Accident (IA) documented, in part, the following: 6/17/24 -Encounter: Nurse stated resident had an unwitnessed fall . IA report: Incident witnessed: No- Resident unable to give description . Immediate Action: ensure that matt is next to bed at all times every time staff enters rooms, resident is moving objects . 6/18/24-Nurses Notes: Nurse heard a bang and went to resident's room. Resident was ambulating unassisted and was leaning against the wall began yelling to writer 'I told you that you should take a shot gun with you' .Resident yelling out nonsense .All discussions seem to center around violence, guns, cutting off heads, stealing and being 'stuck with broken needles' Resident gets very agitated . IA report: Resident lying on floor on the left side of the bed .R (resident) had removed brief and blue jeans were half pulled up. No footwear on .Notes: Resident has history of laying on floor .unable to communicate needs .Resident did not have night ware on .care plan updated to ensure resident is wearing sleeping clothes at night . 6/20/24-Nurses Notes: .Bump and bruising to right forehead and right eye . IA report: Observed lying on floor next to bed .It was observed resident's peg tube had dislodged .resident taken to ER (emergency room) resident experiences confusion and often unable to communicate needs .care plan undated with nonskid foot ware as resident allows. *The resident returned from the hospital on 7/4/24. 7/10/24 -Nurses Notes: Resident found on floor laying next to overturned wheelchair. Resident not able to verbalize how he got on floor .Resident had also pulled out all clothes in drawers and closets and threw them all over the room . IA report: Immediate action: Continuing to monitor resident to maintain his safety and staff safety .care plan updated to remove excess furniture . 7/11/24 - Nurses' Notes: Found resident on floor in room. Resident was laying on his back with pieces of blinds in his hand .also the bed control .Resident not able to tell how he got on the floor .Nursing management .were notified. IA report: .Immediate Action: Bed control removed from room .Called NP (nurse practitioner) on call and she suggested 1:1 sitter and maybe adding care plan .because of continuous falls .Called nursing management and notified them of NP suggestion and they stated they would bring it up in morning meeting .Notes .Care plan updated for provider to evaluate medications and add pain medication as indicated. *It should be noted there was no documentation in the resident's care plan that noted an intervention to provide a 1:1 sitter. 7/17/24- Nurses' Notes: .R35 appears as if he was eating chocolate ice cream due to residue on his hands and face and in his bed. Writer asked if he ate ice cream, and he states yes .unable to provide details .R35 is NPO (nothing by mouth) . 7/18/24 - Progress Notes: .Fall 2x this morning . IA report(s): .9:00 AM .he was sitting against bed with wheelchair in reach .Witnessed: No .Immediate Action: Maintenance added another break to wheel of bed . IA report .10:10 AM . Housekeeper director called nursing staff to back common area on hall and stated resident fell .Incident witnessed: No .Immediate Action: reminded resident to lock wheels before transferring and to ask for assistance . 7/19/24- Pertinent Charting Behavior: .Resident spending most of time in room, occasionally upset because he wants to eat food . 7/23/24- Progress Notes: .R35 seen today for fall .Pt. attempted to transfer self from wheelchair to regular chair, missed it and fell to carpet floor . *No IA was provided for this accident. 7/25/24- Nurses' Notes: .found resident walking down hall naked from waist down .Continue to monitor . 8/1/24 - Nurses' Notes: .Resident was found at the end of his bed on the floor. Mattress was halfway off bed and resident went to floor off mattress .Maintenance request sent as urgent to place foot board at the end of the bed to prevent further falls . IA report: Was this incident witnessed: No . Immediate Action: .there is no foot at the end of the bed . 8/2/24- Nurses' Notes: Resident was demanding to call kitchen to get food and became very irate that he cannot have food by mouth . 8/8/24- Nursing Evaluation: .Resident has a history of frequent agitated behavior .Resident was also evaluated by speech and started on puree diet with 1:1 supervision . 8/8/24-Nurse's Notes: Walked into resident's room and found him bleeding from penis from foley catheter. Resident stated he had stepped on the bag, and it hurts .continued to monitor . 8/21/24-Nurses Notes: .Resident very agitated . IA report: .3:06 PM .Walked into room found resident laying on floor R35 totally naked feces over lower body on legs and back Was this incident witnessed: No .Immediate Action: .managed to walk R35 to bathroom . 8/21/24-Nurses'Notes: .Found resident on floor laying on top of blue foam cushions. Resident was totally naked with feces noted all over lower extremities . IA report: .11:55 PM Was this incident witnessed: No Notes: resident experiences confusion, often doesn't ask for assistance .Resident was self-ambulating when he went to sit on the footrests of his wheelchair . 8/23/24-Pertinent Charting Behavior: Between 2 AM and 4 AM resident was seeking food. Went to all the carts, dining room, and onto unit 2 .Yelling I want food . 8/29/24-Encounter: Resident fell to floor and hit back of head on floor. 2-inch laceration noted which will most likely need sutures. Ok to send to ED (emergency department) . IA report: Resident was walking and pushing his wheelchair attempted to redirect .he began running and fell .hit his right brow and lower eye lid on either the floor or the back of the wheelchair when he fell .Resident reported that he thought the nurse was going to try to give him a bolus tube feeding and was running away .Was this incident witnessed: No Immediate Action Taken: resident would be sent to ER for assessment .d/t (due to) 2 recent falls with head involvement .skin tear flap hanging down from right lower eye lid .Staff have noted resident to be more difficult to redirect recently related to changes in tube feed administrative times .Care plan updated to staff to discourage resident from pushing wheelchair while walking as needed . 8/29/24-Progress Note: Resident returned from ER (emergency room) at 8:40 AM. 3 staples to back of head . 8/30/24-Nurse's Notes: Found resident at end of poppy hall, eating a cookie and trying to remove puddings from med cart . 8/30/24-Progress Note: EMS (emergency medical services) here to transport resident for psych evaluation . *It should be noted that the resident remained in the hospital through 9/9/24. Hospital records pertaining to the residents' psychological concerns were not located in the resident's clinical record. A request was made to provide the documentation. 9/12/24-Progress Notes: .R35 is seen today for fall. It was unwitnessed .found next to his bed . IA report: .was this incident witnessed: No .Notes: Care plan updated for sleep diary . 9/12/24-Nurses' Notes: resident opened up the food cart and removed tray and going down hall with food tray . 9/14/24-Pertinent Charting Behavior: .Resident took a plate of food from lunch caddie .Writer approached resident and he had a fistful of French fries and actively shoving them in his mouth .Writer convinced resident to spit out what he hadn't already swallowed .Resident was continuously leaving the hall in search of food or drinks . 9/15/24: IA report .10 PM .Was this incident witnessed: No .Notes: care plan updated to encourage resident to keep wheelchair within reach. 9/16/24-Progress Notes: .seen today for Slide off wheelchair twice this weekend . IA report: .1:48 AM .Resident was with a small cup of water while wheeling himself down the hallway. When staff attempted to get the cup, the resident became upset and threw the cup .followed him .when the resident went to transfer himself from his wheelchair to a chair he missed and fell to the floor Notes: .R35 recently returned from hospital stay where a diet order was in place for 1:1 assistance with meals .resident was drinking unsupervised .care plan updated for medication review. 9/16/24: IA report: 12:10 AM Was this incident witnessed: No .Notes: resident often chooses to self-transfer and has an increase in behaviors related to receiving enteral nutrition .Care plan updated for staff to encourage resident to be in common areas while awake on night shift and to offer 1:1 activity to resident. A review of R35's care plans documented, in part, the following: Focus: Resident has an ADL (activities of daily living) self-care performance deficit .Interventions: Ambulation: walker or wheelchair (6/13/24) .Bed Mobility-1 person assist (4/22/24) .Eating -NPO at this time (4/29/24) .Transfers -1 person (4/29/24) . Focus: Resident is at risk for falls/injury related to potential seizure activity, history of falling, takes psychotropic medication and cognitive deficits .Interventions: .Discourage resident from pushing wheelchair while walking as needed (8/29/24) .Encourage resident to be in high visibility areas while awake (8/22/24) .Encourage resident to keep wheelchair within reach (9/16/24) .Encourage resident to lock wheelchair breaks before standing up (8/29/24) .Frequent rounding while resident in room (6/14/24) .Sleep Diary (9/12/24) .Staff to ensure bed height to be at residents knee level .(6/14/24) .Staff to ensure wheelchair is locked when resident not in it (7/19/24) .Encourage resident to keep needed items within reach (4/22/24) .Encourage resident to use call light (4/22/24) .Encourage the resident's room is free from accident hazards .(9/15/24) .Non-skid footwear to reduce the risk of slipping .(6/20/24) . Focus: Resident is at risk for altered nutritional status related to: Enteral nutrition via PEG .NPO .Chooses to consume orally despite NPO/pleasure feeds offered during therapeutic setting .Interventions: Keep all food off hallway and dinning room when resident is up. Resident known to get into uneaten food (8/17/24) .Resident is NPO (4/24/24) . Review of a document titled, Department of Health and Human Services - Comprehensive Level II Evaluation (8/6/24) .reported, in part, the following: .R35 .Diagnoses: Schizoaffective disorder, Bipolar type-primary .Recommendations: R35 was living in a group home .but is reportedly unable to return there due to his feeding tube. From reports, it appears R35 would be more satisfied if he were able to have small amounts of pleasure foods. This is allowed in the results of his swallow study, yet the nursing facility reported that he must be on hospice to receive this . A swallow study dated 6/19/24 noted the following: .Recommendation .Supervision Swallow Recommendations: 1:1 .Position Swallow Recommendation: Upright 90 degrees .Swallow Precautions Recommendations: Small bites of food .Discharge Recommendations: NPO with PEG as primary source of nutrition, hydration, medications. R35 may have bites of puree consistency foods for comfort . On 9/19/24 at approximately 10:36 AM an interview and record review were conducted with the DON. The DON was queried as to the multiple falls sustained by R35 and the interventions that were introduced to try to reduce them. The DON noted that the resident was very impulsive, non-compliant and had several behavior issues. The DON noted that initially they tried to remind the resident to utilize their call light, lock their wheelchair and wear proper footwear, but that did not always work. They further reported that were seeking to adjust the resident's medications to ensure they are getting a good sleep. The DON stated that R35's behaviors seem to get worse when they do not get their necessary sleep. In September 2024 they started to keep a sleep diary. The DON was asked why the facility did not follow the NP's recommendation (dated 7/12/24) that R35 receive 1:1 sitter due to excessive falls. The DON noted that they did not implement the recommendation and indicated that due to the resident's behaviors, including behaviors towards staff, that would require two staff to always assist the resident and the facility was not able to provide that care. The DON was asked about the resident's attempts to obtain food that led to falls and/or potential injury. The DON noted that they were aware the resident attempted to obtain food and on more than one occasion was able to grab and consume food. The DON was then asked if the resident required additional supervision to ensure the resident was not grabbing and consuming food on their own again. The DON noted that staff will try to redirect the resident if they are observed trying to obtain food, but again there is no direct 1:1 supervision currently being provided. The DON reported that they were trying to work with the resident's Legal Guardian to try to obtain permission to place the resident on Hospice so that they could have potential pleasure trays during meals, however the Guardian was not responsive to the request. The DON did indicate that the only person providing food was the Speech Therapist. On 9/19/24 at approximately 11:17 AM, an interview was conducted with Speech Therapist (ST) V regarding 1:1 feeding assistance for pleasure trays that may have the potential to reduce falls. ST V confirmed that they are the only person providing feeding assistance at this time and have not trained any further staff. They also noted that unless R35's Legal Guardian agrees to Hospice they do not feel comfortable allowing other staff to provide feeding assistance. On 9/19/24 at approximately 11:44 AM, an interview was conducted with the Administrator regarding R35's falls and attempts to obtain food. The Administrator reported that they were aware of the incidents and were trying to work with the Guardian as to whether they would agree to Hospice or palliative care for the resident. As to providing 1:1 supervision for R35, the Administrator noted that at this time they did not believe it was needed. On 9/19/24 at approximately 12:30 PM, an interview was conducted with the Ombudsman X. The Ombudsman reported that they were at the facility to discuss concerns brought up by R35's Legal Guardian. According to Ombudsman X, R35's Legal Guardian had reported concerns related to falls and the failure to feed the resident a pleasure tray without being a Hospice resident. Ombudsman X noted that the Legal Guardian reported that prior to admission to the facility the resident had minimal behavior issues and limited falls and felt that if the resident were to receive feeding it might limit falls and behavior issues. Review of the facility policy titled, Fall Prevention Program (10/26/23) documented, in part:; Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Policy Explanation and Compliance Guidelines: .Each resident's risk factors .will be evaluated when developing the residents comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R2 On 8/29/23 at 10:30 a.m. Resident #2 was interviewed about having heel or puffy boots or does the facility do anything special for his legs while he is in bed. Resident #2 replied, No they do not do anything for my legs while in bed. I do not have any boots, I have my shoes over there in the corner. On 8/30/23 at 09:00 a.m. Resident #2 was observed in bed with no puffy boots or heel protecters on. There was also no extra pillows or blankets (utilized to offload pressure) observed on the foot of bed where resident could have potentially been able to float his heels. There were no heel boots in the resident's room. On 8/30/23 at 09:07 a.m., Nurse K was asked how did the facility manage the wounds on Resident #2's right ankle, she stated, The wound is very small so we just use 4x4 foam border gauze. Nurse K was asked if Resident #2 wore or has heel boots/ puffy boots. Nurse K stated, No, he does not have any of those and if he did he probably would not keep them on. He self-transfers and he is in and out of his bed and chair all the time. On 8/30/23 at 09:30 a.m., CNA L was asked if Resident #2 removed any heel boots or puffy boots. CNA L stated, No he does not wear those, he doesn't even have any that I have seen. On 8/31/23 at 08:53 a.m., Resident #2 was observed with no heel boots or puffy boots on. Record review revealed the care plan of Resident #2 with an intervention to float heels when laying in bed with puffy boots or pillows per residents preference. Based on observations, interviews, and record reviews the facility failed to ensure appropriate interventions were implemented as ordered timely and consistently to prevent the development and or worsening of pressure ulcers for three (R2, R100, and R522) of four Residents reviewed for pressure ulcers, resulting in the development of additional wounds and the likelihood of the worsening of wounds and pain. Findings include: R100 R100 was a long-term resident of the facility admitted on [DATE]. R100's admitting diagnoses included stroke, dementia, chronic left heel ulcer, seizures, peripheral vascular disease, and history of polio. R100's Brief Interview for Mental Status (BIMS) score of 3/15, indicative of significant cognitive deficits. R100's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/5/23 revealed that R100 needed extensive assistance from two staff members to assist with their mobility in bed and extensive staff assistance from 1 to 2 staff members with their Activities of Daily Living (ADL). An initial observation was completed on 8/29/23 at approximately 10:35 AM. R100 was observed lying on their bed on their back. R100 bed had an alternating pressure mattress and was positioned in the low position. R100's bed was positioned against the wall on the right side. R100's heels were in direct contact with the surface of the bed. Both heels had a dressing covered with gauze. There were no pillows or offloading cushions or heel boots (pressure relieving heel protection boots). There was a Broda chair (a tilt in space reclining chair with wheels) in R100's room, next to the bed on the left side. There were two heel boots on the Broda chair together with other resident belongings. Later that day, at approximately 4 PM a second observation was completed. During this observation, R100 was observed in their bed lying on their back. R100's both heels were resting on the surface of their bed. The two heel boots were observed on the Broda chair on the same spot as before and the chair was parked next to the left side of the bed. On 8/30/23, at approximately 8:45 AM a follow up observation was completed. R100 was lying on their bed and was not dressed. R100 had a facility provided gown and had moved part of their covers/blankets. R100's heels were in direct contact with the bed. There were no pillows under their feet or near their feet. They were awake and asking for help and staff were notified. The Broda chair was parked next to the bed and two heel boots were on the chair. During this observation the surveyor asked if he could call R100's spouse and R100 replied yes. A called was placed to R100's spouse. At approximately 10:45 AM, another observation was completed. During this observation, R100 was observed in the same position on their back. The gauze covers on the heels were partially off and R100's heels were directly resting on the surface of the bed. Two heel boots were observed on the Broda chair next to the bed. Later that day (8/30/23), at approximately 1 PM another observation was completed. During this observation R100 was in their gown, lying on their back. Both heels were in direct contact with bed surface. Both heel boots were observed on the Broda chair parked next to the bed. At approximately 3 PM a follow up observation was completed. R100 was observed in bed with a gown on, with their eyes closed. R100's heel dressings were partially off on both heel with brown stains on them. Both heels were resting directly on the surface of the mattress. The two heel boots were observed on the same spot in the Broda chair next to R100's bed. On 8/30/23 at approximately 3:50 PM another observation was completed. During this observation assigned RN (Staff member S) was present in the room. R100's heels were resting on the bed surface. Staff member S checked the dressing on both heels that were stained and not properly secured. Staff member S reported that they were dated for 8/29/23. Staff member S reported that R100's dressing changes were done daily, on mid-night shift. Staff member S reported that they were going to change the soiled dressings. Staff member S was queried about the two heel boots that were on the Broda chair. Staff member S reported that they should be on while in bed and not sure why they were not on. Staff member S reported that they would change the dressings and put the heel boots on. It must be noted that a total of six observations at different times/shifts were completed between 8/29/23 and 8/30/23. R100 did not have their protective heel boots on during these observations. A review of R100's Electronic Medical Record (EMR) revealed that R100 was admitted with an unstageable left heel pressure ulcer. admission skin assessment, section under describe other foot problems, read in part .pressure to heel, black, per hospital reports, unstageable. The preventative foot care section of the assessment read, resident arrived with heel boots. R100 had a Braden assessment (Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores) score of 16 (dated 2/5/23) indicative of mild risk for pressure ulcer. A review of the Braden assessment dated [DATE] revealed a score of 15, indicating a mild risk for pressure ulcer development, despite their diagnoses and comorbidities. A review of R100's hospital referral documentation also revealed a lower extremity arterial doppler (study of blood flow in legs) results. The results revealed no arterial occlusive disease (no blockage) in right lower extremity and mild arterial occlusive disease (mild blockage) in left lower extremity. Review of R100's EMR revealed a physician order that read, Bilateral heel boots to be worn at all times, dated 8/17/23. Another ordered dated 8/13/24, read wound left heel, right heel, and right ankle: cleanse with wound cleanser, pat dry. Apply honey gel and calcium alginate to wound bed. Cover with pink silicone foam. Please wrap from ankle to calf with kerlix for protection, every night shift for wound care. Another order dated 8/20/23 read, ensure air mattress is on and operational every shift. It must be noted that R100 had a recent admission to hospital on 7/27/23 and readmitted back to facility on 7/31/23. R100 was readmitted back to the facility with a chronic left heel wound and no treatments were initiated until 8/13/23 (13 days after readmission to the facility) based on the orders and review of the treatment administration record. A review of orders also revealed that preventative interventions to protect the heels (heel boots) that R100 was originally admitted with were not in place after readmission on [DATE]. Bilateral heel boots were reordered on 8/17/23 (17 days after readmission back to the facility). Further review of R100's EMR revealed a nursing progress note dated 7/23/23 (prior to recent hospitalization), that read in part, .apply medi honey to wound bed only. Apply alginate to wound bed place foot back in heel protector. A nursing progress note after readmission, dated 7/31/23 at 17:14, read, Also on admission skin assessment right malleolus scabbed over area and several scabbed over areas on bilateral lower extremities from flaked off skin. Wound care referral. There was no documented evidence that wound care was initiated timely. Further review of physician orders revealed an order dated 8/10/23, (10 days after readmission to facility) that read, wound care team to follow patient as warranted. A review of R100's skin assessment dated [DATE], revealed a facility acquired stage 3 pressure ulcer (pressure injuries that extend through the skin into deeper tissue and fat) on right heel with the following measurements: Length of the wound: 1.14 cm; width of the wound 0.89 cm; and depth of the wound 0.2 cm. It must be noted that were no documented skin assessments prior to 8/20/23 reflected that R100 had an acquired right heel pressure ulcer. A review of practitioner note dated 8/8/23, revealed that R100 had right heel and right ankle facility acquired pressure ulcer that were present on 8/8/23. The practitioner note read in part, Chief complaint: Evaluation of wound left heel, right heel, and right ankle. assessment and plans: Pressure ulcer of right heel, unspecified stage: cleanse with wound cleanser, pat dry,. Apply honey gel and calcium alginate. Cover with bordered foam. Pressure ulcer to left heel, unspecified stage: cleanse with wound cleanser, pat dry,. Apply honey gel and calcium alginate. Cover with bordered foam. Pressure ulcer of right ankle, unspecified stage: cleanse with wound cleanser, pat dry. Apply honey gel and calcium alginate. Cover with bordered foam. It must be noted that these wound treatment orders were initiated on 8/14/23 (7 days after the practitioner's wound consult and 13 days after readmission to the facility). A review of R100's care plan revealed the interventions that included, Encourage and assist as needed to elevate heels off of the mattress as tolerated; preventative treatment per orders, pressure redistribution mattress to bed, with an effective date of 8/15/23 (15 days after readmission to facility). An interview with R100's spouse/responsible party was completed on 8/30/23 at approximately 9:45 AM. During the interview the responsible party reported that they had not been receiving communications from the facility staff members. R100's spouse/responsible party reported that they were not aware of the pressure ulcer on the right heel. They had confirmed that no one from facility had called and notified them of the pressure ulcer on R100's right heel pressure ulcer. An interview with was completed with the unit manager (staff member O) on 8/30/23, at approximately 3:55 PM. Staff member O was queried on facility acquired stage 3 pressure ulcer on the right heel and the preventative measures that were in place for the R100. Staff member O reported that R100 was being followed by the wound team and the facility used heel boots or pillows or heel up cushions to off load and protect the heels. Staff member O was queried on why staff were not following the orders and not assisting R100 with off loading and protecting their heels. Staff member O' reported that R100 refuses at times. Staff member O was notified on the multiple observations when R100 was not offered and assisted with offloading the heels with heel boots or alternate interventions. Staff member O reported that staff should follow the orders for the wounds to heal and they would follow up with their staff. An interview was completed with the Director of Nursing (DON) on 8/30/23 at approximately 10:25 AM. The DON was queried about the facility acquired stage 3 pressure ulcer and the facility's plan. The DON reviewed R100's EMR and reported that the right heel pressure ulcer was identified on 8/20/23. The facility wound care nurse followed up on the wound treatments and obtained orders from the attending physicians and practitioners. As noted above, the skin assessment report revealed that the right heel ulcer was identified on 8/20/23. But the practitioner note dated 8/8/23, revealed that they had done a wound consult on 8/8/23 for the right heel wound. A follow up interview was completed with the DON on 8/31/23, at approximately 12:50 PM. The DON was queried on their facility policy on following preventative measures as ordered. The DON reported that expectation is treatments and other interventions should be continued as ordered. The DON reported that R100 had an order for heel boots to be on at all times and staff are expected to assist resident with heel boots. The DON reported that they would follow up with their staff and agreed with concern. A facility provide document titled Pressure injury prevention and management with a revision date of 1/1/22, read in part, The facility is committed to prevention of avoidable pressure injuries and promotion of healing of existing pressure injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to skin and or underlying soft tissues usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of interventions; or revise the interventions as appropriate. Policy Explanation and Compliance Guidelines: 1. There are multiple terms used to describe type of skin damage, including pressure ulcer, pressure injury, decubitus ulcer, and bed sore. For purposes of this policy, pressure injury as the current standard terminology, will be used. 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying interventions as appropriate. 3. Assessment of Pressure Injury Risk: a. Licensed nurses will conduct a pressure injury risk assessment, using [NAME] or Braden tool on all residents upon admission/re-admission, weekly x 4 weeks, then quarterly or whenever the resident's condition changes significantly . R522 On 8/29/23 at 10:42 AM, R522 was up to their Broda Chair in the common/dining area of the memory care unit. They were observed to be seated in the chair with no specialized cushion for offloading pressure and no soft heel boots in place to protect the feet from skin breakdown. On 8/29/23 at 12:37 PM, R522 was observed eating their lunch meal in the dining room. No offloading cushion or heel boots were observed in place at that time. An observation of their room revealed soft heel boots were placed on the stripped bed. On 8/29/23 at 12:48 PM, a review of R522's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: late onset Alzheimer's disease, dementia, protein calorie malnutrition, anxiety disorder, and falls. R522's MDS assessment dated [DATE] revealed they had severely impaired cognition and required assistance from staff for activities of daily living. The MDS assessment indicated they did not admit to the facility with any pressure ulcers. A review of a Skin & Wound Evaluation Dated 8/27/23 revealed R522 developed an unstageable pressure ulcer (Full thickness tissue loss in which the base of the ulcer is covered by slough, and/or eschar in the wound) to their right heel. A review of R522's physician's orders was conducted and revealed a treatment order to the wound dated 8/27/23, an order for, Heel protectors to be worn at all times dated 8/27/23, and an order for Pressure redistribution surface while seated dated 8/27/23. On 8/29/23 at 1:53 PM and 2:10 PM, and 8/30/23 at 9:15 AM, 11:18 AM, and 12:10 PM, R522 was observed seated in their Broda chair in the dining/common area. It was not observed R522 had heel boots, or an offloading cushion in place. On 8/30/23 at 12:15 PM, an observation of R522's wound care was observed with nurse 'C', R522's assigned nurse. R522's right heel revealed a wound approximately 1.5 inches in diameter with undeterminable depth, covered in yellowish slough and blackened tissue around the perimeter of the wound. It was further observed the wound had moderate, foul smelling drainage that had seeped through the dressing and into the gripper sock. At that time, Nurse 'C' was asked if the left heel could be observed. The left lateral heel revealed a fluid filled blister approximately the size of a quarter. On 8/31/23 at 11:40 AM, R522 was observed seated in their Broda chair in the common/dining area. R522's heels were observed on the ground and no heel boots or offloading cushion were observed in place. At that time, nurse 'P' (R522's assigned nurse) was asked if R522 had any wounds. Nurse 'P' reported they had a wound on their right heel, but did not mention any concerns with the left heel. They were asked if they could remove R522's gripper sock the the left heel could be observed. When the sock was removed the left heel revealed a fluid filled blister that was approximately double in size than the previous observation on 8/30/23. On 8/31/23 1:15 PM, an interview was conducted with the facility's DON regarding the observations of the heel boots, offloading cushion, and identification of the blister on 8/30/23. They said the interventions should have been put in place when ordered and when the new blister on left heel was identified, a treatment order should have been put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #138289 Based on interview and record review the facility failed to ensure adequate supervision was provided for three cognitively impaired residents (R80, R88 and R110) of seven residents reviewed for accidents, when on 6/15/23 R80 followed by R110 and R88 wandered into another resident room, (unsupervised by staff) which resulted in R110 pushing R88 over and R88 sustaining a nondisplaced fracture of the femoral neck, hospitalization requiring surgery and pain. Findings include: Resident #110 On 8/29/23 a facility reported incident (FRI) submitted to the Stage Agency was reviewed which indicated on 6/15/23 R110 pushed R88 over which resulted in R88 falling down and receiving a fracture of their left hip. On 8/30/23 the medical record for R110 was reviewed and revealed the following: R110 was initially admitted to the facility on [DATE] and had diagnoses including Dementia with other Behavioral Disturbance. A review of R110's MDS (minimum data set) with an ARD (assessment reference date) of 7/15/23 revealed R110 was independent with ambulation. R110's BIMS score (brief interview for mental status) was three indicating severely impaired cognition. A review of R110's progress notes revealed the following: 6/12/23-Resident was following around [R80], when [R110] asked [R80] to do something and [R80] did not do it [R110] spanked [R80] on her butt. 6/15/23-Approx (approximately) 7:00pm resident had physical aggression with another resident [R88] Resident was following around [R80] when [R88] decided to intervene. Resident pushed [R88] to the ground. when asked what she was doing [R88] stated that Resident would not leave [R80] alone. A review of R110's careplan revealed the following: Focus-Resident has impaired communication related to: Alzheimer's disease, dementia, and age-related cognitive decline .Interventions-Anticipate and meet the resident's needs . Resident #88 On 8/30/23 the medical record for R88 was reviewed and revealed the following: R88 was initially admitted to the facility on [DATE] and had diagnoses including Vascular dementia with other behavioral disturbance, Muscle weakness and Delusional disorders. R88's MDS with an ARD of 3/23/23 revealed R88 needed supervision from facility staff with ambulation. R88's BIMS score (brief interview for mental status) was nine indicating moderately impaired cognition. A review of R88's progress notes revealed the following: 6/15/23- Approx 7:00pm resident had a physical interaction with another resident [R110]. Resident stated that she saw [R110] not leaving [R80] alone. [R88] said she went to [R110] and told her to leave her alone. [R110] pushed [R88] and [R88] fell to the floor. Resident was sent to the hospital approx 7:10pm due to extreme pain in the hip and unable to bear weight on the leg. POA (power of attorney) called approx 9:15pm stating that resident has broken her hip and was getting surgery tomorrow (Friday). 6/19/23-resident arrived VIA EMS (emergency medical services) approx 3:45pm after a fall at [Name of facility]. Resident had a left femoral neck fracture and received surgery for it. A Physician hospital note dated 6/15/23 revealed the following: History of present illness This patient from [Name of facility] nursing home presents after a fall. Patient was apparently pushed by another roommate. There was no loss of consciousness. Patient apparently injured her left hip and has been complaining of left hip pain since the fall. Patient is now having difficulty ambulating .Work-up .X-rays of the left hip, acute nondisplaced fracture of the left femoral neck .Assessment plan: 1. Status post fall, mechanical 2. Nondisplaced left femoral neck fracture Orthopedics consulted Surgery is planned later today . A review of the facility investigation pertaining to the altercation between R110 and R88 on 6/15/23 was reviewed and revealed the following: Investigation Summary/Actions Taken: On 6/15/2023 at approximately 7:00PM CNA (Certified Nursing Assistant) [CNA N] observed Resident [R110] (Bimms <sic> 3) (severe cognitive impairment) push Resident [R88], causing her to fall to the floor onto her left side. [CNA N] escorted [R88] <sic> what she was doing and she stated that [R110] was going after [R80]. Staff immediately separated the two residents and the nurse conducted a skin check noting extreme pain to her left hip and she was unable to put weight on her left leg. Resident, [R110] was immediately put on a 1 :1 and was referred to the providers for a medical work-up. [R88] responsible party and Physician were notified about the incident, [R110] responsible party and Physician were notified about the incident. [R88] was sent to the ER (emergency room) per Physicians order do to possible fracture. The nurse conducted a skin check on [R110] and noted a scratch on her right wrist from [R88] reaching out trying not to fall. On 6/16/23 at 2:59AM the hospital called the facility to report that [R88] had a left femoral neck fracture. All unit staff that were working at the time of the incident and no one saw [R110] push [R88]. But they did state that throughout the day they had been redirecting [R110] away from another resident named [R80] and it seemed that [R88] had picked up on this and was trying to keep [R110] away from the other resident .[R88] returned to the facility on 6/19/23 after receiving surgery to her left hip. She is now using a wheelchair with minimal discomfort. Due to [R110] still trying to follow [R80] she will remain on a 1:1 until staff can get her to focus on other things. [R80] is very small and childlike. [R110] sees [R80] as her responsibility and continues to try to be near her .The IDT (interdisciplinary team) through its investigation found that [R88] was trying to keep [R110] away from [R80] causing [R110] to get upset and push [R88] making her fall to the ground. [R110] remains on a 1:1 due to her still trying to follow [R80]. Based on the interviews and the facts of the investigation the facility was able to substantiate that a physical altercation occurred but was not able to substantiate that any abuse had occurred due to the inability to form intent due to cognitive deficits for both [R110] and [R88]. At this time [R110] is at baseline and resting comfortably in the facility and states that she feels safe and secure. [R88] has to now use a wheelchair until her hip fully heals, she uses the wheelchair with minimal discomfort and state that she feel safe and secure at the facility . An incident and accident report dated 6/15/23 pertaining to the altercation between R110 and R88 revealed the following statements from staff: CNA N-[CNA N] states she was coming out of room [ROOM NUMBER], she came down the hall and saw [R110] shove [R88]. they were In the doorway of room I. [R88] lost her balance and fell sideways onto the floor, [CNA N] asked [R88] what she was doing and [R88] stated that [R110] was going after [R80] .Nurse P-[Nurse P] states that she had left prior to the incident occurring: States resident was needing to be redirected away from the resident (R80). [R88]. was telling resident to stay away from throughout the day .CNA Q-[CNA Q] states she was In another residents room at the time of the Incident .[CNA R] was not on the unit yet . On 8/31/23 at approximately 12:30 p.m., during a conversation with CNA A and Nurse P, CNA A was queried regarding the behaviors of R110 on 6/15/23 and they reported that they frequently had to redirect R110 from following R80 around. CNA A was queried regarding the supervision needed for R110 and they indicated that R80 will walk into other resident rooms all day and that they do not have enough staff on the unit to appropriately supervise the residents that that is when residents to resident altercations occur. On 8/31/23 at approximately 1:05 p.m., CNA N was queried regarding their observation of R110 pushing over R88 on 6/15/23. CNA N indicated they were coming out of a resident room down at the end of the hall and saw R80 was wandering in another resident room with R110 following them in. CNA N reported that R88 tried to get R110 to stop following R80 at the doorway to the room. R110 pushed R88 over and they fell in the hallway and were not able to get up. CNA N was queried how the staff were providing supervision for the residents in the altercation when R110 had been noted to be following around R80 and they indicated they were unable to monitor them because they had to help another resident and the Nurse had gone on break. CNA N reported no one was able to watch the residents until they saw R110 push R88 over. CNA N reported there was no Nurse on the locked unit at that time, because the Nurse assigned to the unit was on break and they had to leave the locked unit to get another Nurse after R88 had fallen. CNA N was queried if they had enough staff members to monitor the residents on the locked unit and they indicated that they did not. CNA N reported there were other residents that needed 1:1 supervision because they frequently try to stand up and are a big risk for falling, so they have to watch them and are not able to watch the other other residents who are cognitively impaired and ambulatory. On 8/31/23 at approximately 2:21 p.m., The Director of Nursing (DON) was queried regarding the lack of supervision being provided for the cognitively impaired residents on the locked unit. The DON indicated that they try to staff it with an adequate amount of staff to watch everyone but that is only when the facility has enough staff on the other units to provide care. The DON indicated the staff assigned to the locked unit should be aware of who needs to be monitored. On 8/31/23 a facility document titled Accidents and Supervision was reviewed and revealed the following: Policy .Each resident will receive adequate supervision and assistive devices to prevent accidents .5. Supervision-Supervision is an intervention and means of mitigating accident risk The facility will provide adequate supervision to prevent accidents .