**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00147582. Based on observation, interview and record review, the facility failed to provide appropriate supervision, follow and implementtimely interventions for three residents (Resident #1,Resident #2 and Resident #3) of three residents reviewed for falls, resulting in repeated unwitnessed falls, an eyebrow laceration, right hip and left hip fractures with the likelihood of further falls and/or injuries. Findings include: Resident #1: On 10/23/2024, at 10:00 AM, Resident #1 was resting in a reclined geri-chair in the therapy room with the speech therapist. On 10/23/24, at 10:10 AM, a record review of Resident #1's electronic medical record revealed an admission on [DATE] with diagnoses that included intellectual disability, repeated falls and Dementia. Resident #1 had severely impaired cognition and required assistance with all Activities of Daily Living. A review of the Fall Risk Evaluation admission 9/6/2024 revealed total score is 16 Total score of 5 or above is HIGH RISK. A review of the Physical Therapy PT Evaluation & Plan of Treatment Start of Care: 9/8/2024 revealed . Ambulation Walk 10 feet = Supervision or touching assistance . A review of the Fall - Unwitnessed . 09/13/2024 11:00 . This nurse called to nursing station, observed staff hoyering res into w/c. Res had fallen and obtained laceration to left brow. Res was assessed by DON, no further injuries noted. Resident unable to give description . Res assessed and received laceration to left brow, area cleansed, Res sent to ER for eval for need of stitches. Confused Gait Imbalance Impaired Memory Balance Problem were all check marked. A review of the corresponding IDT progress note revealed IDT met to discuss resident fall. Root cause determined to be poor safety awareness d/t dementia diagnosis, has history of falls. Intervention for resident to be supervised with ambulation. Care plan reviewed and updated. A review of the Fall - Unwitnessed . 10/9/2024 1350 (1:50 PM) . CNA went to get resident up to take to lunch and when she went in room resident was sitting in wheelchair and said that she fell. Resident had no c/p at this time Resident stated she fell . After lunch RN attempted to get resident out of wheelchair. Resident was able to stand but unable to walk, right leg would give out. (physician) notified and Xray ordered . Injury location Right trochanter (hip) . Confused Gait Imbalance Weakness/Fainted Balance Problem were all check marked. A review of the progress notes revealed: 9/23/2024 . Sutures removed from left eyebrow . 10/7/2024 12:30 . Resident has been becoming increasingly restless. She is pacing and wandering into others rooms . 10/9/2024 14:14 Resident stated she fell in room prior to lunch. No injuries noted or c/o of pain at that time. After lunch resident returned to unit and was unable to walk. Resident could stand but when attempt to walk right leg would give out. Resident would grab right leg as if it was painful. Xray ordered. No visible injuries noted. 10/9/2024 17:30 . X-ray came out Right Hip fx (fracture) present notified DON and (physician) resident sent to hospital via (ambulance). 10/15/2024 11:34 IDT met to discuss resident fall. Root cause determined to be poor safety awareness r/t dementia, and unsteady gait. Intervention for lipped mattress to be placed in bed. Resident had Xray ordered immediately, with results of fracture, send to ED for further eval/treatment. Care plan reviewed and updated accordingly. 10/13/2024 14:59 Resident readmitted from (hospital), assisted from gurney to bed to recliner chair due to restlessness . 10/15/2024 17:50 Late Entry: admission visit for right hip pain status post ORIF (open reduction internal fixation) . Open reduction internal fixation is a surgical repair of the hip fracture. A review of the facility provided Investigation Form 10/11/2024 revealed CONTRIBUTING FACTORS AND INTERVENTIONS . Resident with multiple falls prior to admission . A review of the care plan revealed Focus Fall Risk: (resident) is high risk for falls r/t weakness, incontinence, poor safety awareness Date Initiated: 09/06/2024 . Interventions Anticipate and meet the resident's needs. Date Initiated: 09/06/2024 Environment: Keep my room free of potential fall hazards - clutter, spills, tripping hazards, poor lighting, etc. Date Initiated: 09/10/2024 Follow facility fall protocol. Date Initiated: 09/10/2024 Gripper socks to be utilized unless wearing hard/rubber soled shoes Date Initiated: 09/10/2024 Ortho B/P's x 2 days Date Initiated: 09/13/2024 PT to evaluate and treat as ordered or PRN. Date Initiated: 09/10/2024 Focus The resident has had an actual fall with injury Date Initiated: 09/13/2024 . Interventions Date and description of other interventions put in place after a fall: 9/13/24-Supervised when awake while in common areas, sent to ED for stitches to L eyebrow 10/9/24-Xray ordered, New med order rec'd, Lipped mattress, floor mat in place. Date Initiated: 09/13/2024 Resident #2: On 10/23/24, at 11:35 AM, Resident #2 was in their room in their wheelchair. Their family was present. Resident #2 denied they fell and hurt themselves and their family reminded them they fell and broke their hip. A review of Resident #2's electronic medical record revealed an admission on [DATE] with diagnoses of Chronic obstructive pulmonary disease, Dementia and repeated falls. Resident #2 had severely impaired cognition and required assistance with Activities of Daily Living. A review of the Fall Risk Evaluation admission 9/26/2024 revealed total score is 18 Total score of 5 or above is HIGH RISK. A review of the Fall-Unwitnessed . 10/2/2024 21:00 . CNA going to answer call light on C-Hall, when she swa resident seated on floor, called for nurse assistance. This nurse entered room and observed resident lying on her L side, in between her w/c and bed. Legs outstretched, w/no immediate injuries observed. States I tried going by myself but I'm too weak. Unable to state if she was attempting to transfer to bed or bathroom . Confused was check marked. A review of Fall-Unwitnessed . 10/5/2024 09:23 . Resident from across hall called out to writer, Writer observed (resident) laying on the floor, on her right side, with her food tray across the front of her, bed table on it's side, (resident) stretched out towards the bathroom door, hold her left hip complaining of pain . Stated she did not remember than stated she was trying to go to the bathroom . assessed resident for injury, neuros started, lifted with mechanical lift back in to bed. Attempted to assess for injury to left hip but will not allow writer to straighten legs. Once in bed straighten legs, complaining of pain, grabbing hip . Impaired Memory was check marked. A review of the SBAR-Fall . 10/05/2025 . Resident attempted to self transfer to restroom falling on to the floor unwitnessed. Feet close to bed body extend toward restroom door, Resident laying on right side when observed by writer, bed side table tipped over food tray above head . A review of the Fall-Unwitnessed . 10/12/2024 . Staff entered room alerted by resident yelling out. Resident [NAME] on floor on abdomen next to bed in lowest position on mat next to bed with head toward window. Resident incontinent at time of fall. Resident c/o left hip pain. Resident description I was going to the bathroom . immediate action take . new intervention to toilet before breakfast and have resident up in w/c for breakfast. Obtaining x-ray left hip per order . Injury Location Left trochanter (hip) . Confused Impaired Memory were check marked. A review of the Radiology Report Date of Service 10/12/2024 3:07 PM revealed Results: there is an intertrochanteric fracture at the hip. Conclusion: Fractured hip . A review of the progress revealed 10/16/2024 16:18 . Resident returned from hospital via ambulance. Assisted into bed. No c/o pain, staples to left leg have dry dressing covering . A review of the care plan revealed Focus The resident is at risk for falls r/t impaired cognition, deconditioning Date Initiated: 09/26/2024 Goal The resident will be free of minor injury through the review date. Date Initiated: 09/26/2024 Interventions Anti roll backs in wheelchair Date Initiated: 10/23/2024 Anticipate and meet (resident) [NAME] to deter attempting to self transfer Date Initiated: 09/26/2024 Environment: keep my room free of potential fall hazards - clutter, spills, tripping hazards, poor lighting, etc. Date Initiated: 09/27/2024 Follow facility fall protocol. Date Initiated: 09/27/2024 Gripper Socks to be utilized unless wearing hard/rubber soled shoes Date Initiated: 09/27/2024 keep bed in lowest position while I am resting Date Initiated: 09/27/2024 Padded floor mat to exposed side/sides of bed when resting Date Initiated: 09/27/2024 . Focus The resident has had an actual fall with no injury, fall with major injury 10/1/2024 Date Initiated:10/02/2024 Goal The resident will resume usual activities without further incident through the review date. Date Initiated: 10/02/2024 Interventions Date and description of other intervention put in place after a fall: 10/2/24-Bed moved against wall on right side. Resident to transfer with left side which is her strong side. 10/5/24-Resident to be offered to eat at the nurses station or dining room [ROOM NUMBER]/12/24-Xray; up for all meals, toileted before meals, bed flipped against the wall. Will be moved closer to the nurses station when bed becomes available. Grab bars added per family request as well. Date Initiated: 10/14/2024 Resident #3: On 10/23/24, at 9:30 AM, Resident #3 was resting in their low bed. There was a mat to the floor on the right side of the bed. The left side of the bed was pushed against the wall. On 10/23/24, at 10:30 AM, a record review of Resident #3's electronic medical record revealed an admission on [DATE] with diagnoses that included Dementia, Diabetes and recent subdural hematoma. Resident #3 had severely impaired cognition and required assistance with Activities of Daily Living. A review of the Fall Risk Evaluation admission 7/16/2024 revealed total score is 9 Total score of 5 or above is HIGH RISK. A review of Fall - Unwitnessed . 8/5/2024 . Call light activated. CNA entered room and immediately called for nurse assistance. Resident lying on floor next to bed, w/his head in between bed and nightstand. He's alert, taking, w/no obvious s/s of injury. Resident unable to give Description . Confused Gait Imbalance Impaired Memory were all check marked. A review of the SBAR-Fall Effective Date: 8/05/2024 . Call light activated, CNA entered room and immediately called for nurse assistance. Resident lying on floor next to bed, w/ his head in between bed and nightstand. He's alert, talking, w/no obvious s/s of injury. Unable to state what occurred. ROM and neuro-checks WNL. Refusing full set of vitals at the time d/t confusion. Full skin assessment completed, some redness to L ear observed, skin intact . A review of Fall-Unwitnessed . 8/6/2024 19:00 . CNA walking passed resident room and notified nurse of incident. Entered room and observed resident lying on floor next to bed, on his L side. He's alert and talking w/ no obvious injuries observed. Resident unable to give description . Immediate action taken . Non-compliant w/ wearing grippy socks, confused . A review of Fall-Witnessed . 8/17/2024 20:20 . This nurse head others calling out for help and observed resident laying on his back near nurses station. CNA who was sitting at nurses station stated she observed him falling backwards from standing and fell mostly on his back. Resident unable to give account of events r/t dementia . Resident assisted to bed with use of Hoyer lift . Impaired Memory was check marked. A review of the SBAR-Fall . 8/17/2024 . Resident was observed getting up from seated area and observed slipping and falling backwards. Resident was barefoot at time of fall . A review of Fall-Unwitnessed . 8/18/2024 22:50 . Nursing staff entered room to provide care for resident he was noted to be laying on mat next to bed with head toward door. Resident unable to give description . Immediate action taken . Brief was soiled w/ urine and feces . Confused Gait Imbalance Impaired Memory were check marked. A review of Fall-Unwitnessed . 9/1/2024 19:05 . A review of the SBAR-Fall . 09/01/2024 . At 1845 CNA was walking down C hall and called for nurse assistance. Entered resident's room, observed him seated on floor mat next to bed, alert w/no immediate injuries observed. Unable to state what occurred. ROM, neuro-checks and vitals all WNL. Brief was soiled w/urine and feces. Assisted into bed to provided personal hygiene. No injuries observed to skin and no s/s of pain . A review of the focus (resident) is high-risk for falls r/t poor safety awareness: confusion Date Initiated: 07/16/2024 . Interventions Non-slip material to wheelchair cushion. Date Initiated: 10/01/2024 Anticipate and meet the resident's needs. Date Initiated: 07/16/2024 Assist with routine toileting and PRN to help prevent self-transfers Date Initiated: 07/16/2024 Environment: keep room free of potential fall hazards - clutter, spills, tripping hazards, poor lighting, etc Date Initiated: 07/16/2024 Follow facility fall protocol. Date Initiated: 07/16/2024 Gripper socks to be utilized unless wearing hard/rubber soled shoes Date Initiated: 07/16/2024 If resident becomes restless/agitated, bring res into communal area for increased supervision. If resident refuses, remain with resident until directed by nurse Date Initiated: 07/16/2024 PT evaluate and treat as ordered or PRN. Date Initiated: 07/16/2024 The resident needs activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 07/16/2024 On 10/23/24, at 11:30 AM, Resident #3 remained in the same position. On 10/23/24, at 11:55 AM, CNA C and CNA E in to assist Resident #3 with incontinent care. CNA E offered that Resident #2 ate breakfast in bed and remained in bed since. On 10/23/24, at 1:00 PM, the Director of Nursing (DON) was interviewed regarding the sampled residents and their multiple falls. The DON was asked if there was anything else the facility could have done to prevent the unwitnessed falls and DON responded, well, I cant have one to one while they are in their rooms. Prior to exit, the DON was asked to provide the day of the most recent unwitnessed fall in the facility and the DON, stated, yesterday. A review of the facility provided Fall Evaluation Safety Guideline Effective Date: 11.28.17 revealed . A fall evaluation is used to identify individuals who have predicting factors for falls . Involve interdisciplinary (IDT) on: Individualized assessment for safety Identification of Hazards Need for Supervision Development and implementation of interventions to reduce accidents . Guideline for Evaluation May include: . Fall history . Impaired mobility/functional status Incontinence Cognitive status Mood or behavior indicators . If the evaluation finds the resident at risk, implement resident specific interventions/precautions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate staff training and supervision during facility van transportation and appropriate emergency medical response for one (#216) of one resident reviewed resulting in the wheelchair lift platform not being raised during Resident removal from the facility transportation van, Resident #216 being pulled out of the van in their wheelchair without the platform lift elevated, falling, and experiencing unnecessary pain, lacerations, multiple soft tissue injuries, a cervical spine (neck) fracture, and psychosocial distress utilizing the reasonable person concept. Findings include: An interview was conducted with Anonymous Witness M on 2/16/24 at 10:00 AM. Witness M verbalized concerns regarding Resident #216 being pushed out of the facility wheelchair van in the parking lot. Per Witness M, a facility staff member did not put the ramp up on the wheelchair van when they attempted to remove the Resident from the van resulting in the Resident falling and breaking their neck. Witness M revealed they were also concerned because the facility staff moved the Resident into the facility before calling the ambulance and had not reported the incident to the State agency. Record review revealed Resident #216 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included depression, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), weakness, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required substantial to maximum assistance for transfers, and utilized a wheelchair for mobility. Per the face sheet, Resident #216 was discharged to another nursing home on 6/1/23. A review of documentation in Resident #216's Electronic Medical Record (EMR) revealed the following: - 6/7/23 at 4:48 PM: SNF to ED Handoff Form . Resident fell off lift from wheelchair van in chair approx. 2 feet . Reason(s) for transfer: Laceration to left great toe, difficulty turning neck, pain in both shoulders and arms . - 6/7/23 at 5:25 PM: Post-Fall Evaluation . Post Fall Follow-up . Is there new pain post fall? Yes . Pain Scale is at: 9 . generalized and severe pain neck, head and shoulders . Injury . Yes . Abrasion . Bruise . Cut . Laceration . multiple abrasions and bruising with laceration see SBAR for completer description . Pain . New . increase due to fall . Pain prior to fall controlled with medication Resident sent to ER for treatment and evaluation . resident c/o (complain) of pain with bilateral arm movements and turning head to right . - 6/7/23 at 6:43 PM: Health Status Note . Resident sent out to hospital at 1640 (4:40 PM) due to fall from transport van, multiple bruises, and abrasions, laceration to right great toe. C/o of shoulder pain both shoulders, bump to back of head and c/o of difficulty turning head to right. - 6/7/23 at 7:03 PM: Resident was being removed from van when both resident and transporter fell to pavement. - 6/13/23 at 7:07 PM: SBAR - Fall . Brief description . Transport was returning resident to facility when both resident and transporter fell out of back of van to pavement . Any injury noted? Yes . Location . Vertebrae (upper-mid) Bruising mid back spine . Right hand (back) abrasion with bruising thumb and knuckles . Left hand (back) abrasion index finger, knuckles, thumb with bruising . Right buttock large bruise . Left buttock bruise . Left knee (front) bruising . Right lower leg (front) bruising inner right shin . Back of head hematoma c/o (complain of) of difficulty turning head to right . Right toe(s) abrasions . Right toe(s) great toe with approx. 2-inch laceration . Left toe(s) abrasions . Right shoulder (rear) Right shoulder bruising with pain . Left shoulder (rear) bruising with pain . hematoma to left upper arm near shoulder painful to touch . left rib bruising . right rib bruising . Type of injury . Swelling . Bruising . Laceration . Hematoma . Decreased Mobility/ROM (Range of Motion) . Pain . Yes . Pain elicited by . Passive ROM . general pain all over severe pain in shoulders, neck and head . Send to ER . Facility Incident and Accident reports for Resident #216 were requested. The facility provided a file which included the following: - Incident and Accident Report, dated 6/7/23: Fall . Location: Outside on facility grounds . Description: Transport was getting resident out of van and both fell to the ground . Immediate Action Taken: Resident was assessed (for) injury. Vitals taken. Right foot was cleaned and bandaged for injury to right great toe. Resident taken to (hospital ER) . Injuries . Abrasion: Left finger(s) . Abrasion: Right fingers . Other (Describe): . in notes at bottom . Level of Pain . 10 (out of 10- worst possible pain) . Alert . Wheelchair bound . Mental Status: Orientated to Person . Situation . Injuries Reported Post Incident: Abrasion: Right toes; Abrasion: Left toes; Abrasion; Left Fingers, Abrasion: Right Fingers; Bruise: Vertebrae (upper-mid); Bruise: Right iliac crest (rear); Bruise: Left iliac crest (rear); Bruise: Right buttocks; Bruise: Left buttocks; Bruise: Right knee (front); Bruise: Left knee (front); Bruise: Right lower leg (front); Bruise: Right shoulder (rear); Fracture: Vertebrae (upper-mid); Hematoma: Back of head; Hematoma: Left upper arm . Other Info: Resident being removed from transport van and both resident and transporter (CNA Q) fell to the ground . Witnesses: (CNA Q) . - Typed, undated summary: On June 7, 2023, Transporter (Certified Nurse Assistant [CNA]) Q was moving (Resident #216) in their wheelchair from the back of the van onto the lift. (CNA Q) wheeled patient from van and didn't realize the rear lift was still in the down position. (CNA Q) stepped off the back of van with (Resident #2216) in wheelchair off the ledge and both fell to the ground. (CNA Q hit the ground first with (Resident #216) sill in their wheelchair, landed on top of them. Receptionist (Staff V) was approaching as the incident occurred and immediately called for assistance. (Registered Nurse [RN] W), (CNA Y), (CNA X) immediately assessed (Resident #216) for pain and injuries then lifted (Resident #216) with mechanical lift into wheelchair. (Resident #216) was then directly lifted into bed for further assessment. After further evaluation, (Resident #216) then complained of shoulder pain . transferred to hospital . - Written, undated statement by RN W: Around 4:30 PM, I was called from another resident room to front of building. (Resident #216) was laying on back with blanket under head. Was told resident and transporter fell out of van. Approx. 2 feet. Resident was assisted up with Hoyer (mechanical lift) to wheelchair and taken back to room for evaluation. Multiple bruising to arms, legs, buttocks, side of hands, and feet. Abrasions to fingers and toes. Hematoma to back of head and upper left arm. Laceration the length of right great toe. Resident c/o (complain of) neck pain, head pain 10/10 (worse possible pain) and pain to arms and shoulders 9/10, Resident set to hospital after notifying Doctor for further evaluation and possible sutures to toe . - Written statement by CNA Y, dated 6/7/23 (no time): I was standing at the nurses' station around 4:30 PM when (Staff V) yelled to me for help. I ran out behind them. I seen (Resident #216) and (CNA Q) on the ground. The nurses (RN I), (RN W) and (Licensed Practical Nurse [LPN] Z) checked Resident . Hoyered (Resident #216) back into wheelchair . - Written statement by CNA Q, dated 6/7/23 at 4:20 PM: I transported three residents back to the facility at 4:20 PM. Two residents . were unloaded safely and brought back to their rooms with the help from (Staff V). (Resident #216) was the last one to get out sine they were sitting in the middle part of the van . I used the passenger side door to get back in the van to get resident not realizing the van list is still position to the ground. I pulled resident's wheelchair to get to the platform and we were both on the ground. I had the wheelchair with the O2 (oxygen) tank and the resident on top of me. (Staff V) saw me and the resident on the ground and they immediately called for help. Resident was assessed and was put back in their chair . - Written statement by CNA Q, dated 6/13/23 (no time): I sat with (Resident #216) at 6:28 PM while I was waiting to be seen by and ED provider. At 7:40 PM, Residents family arrived in room. (Family AA) was there ans said they couldn't understand how it happened. (Family AA) looked at me and asked if I was there when it did. I said I was and informed them that I was the one who transported (Resident #216). I explained to them what happened, apologized for what happened . - Written statement by CNA X, dated 6/7/23 at 4:30 PM: I was coming down hall when a resident had pointed to the window and said 'Look!!' I looked out the window and seen (CNA Q) and (Resident #216) laying on the ground behind the van. I ran out to help. We hoyered (Resident #216) back into chair, transferred to bed. An interview was conducted with CNA G on 3/20/24 at 2:09 PM. When queried if they were working on 6/7/23 when there was an incident involving Resident #216, CNA G stated, I was the transporter at that time. When asked what happened, CNA G stated, On the way back (to the facility), I had two more residents in the back. (Resident #216) was sitting closer to me. When asked to clarify if they were saying they were transporting three residents back to the facility, CNA G confirmed they were. CNA G revealed they had to pick up an extra resident on the way back to the facility. When asked what happened when they got to the facility, CNA G revealed they got the other resident's out of the van and stated receptionist Staff V helped me and took the first resident in. CNA G continued, For some reason, I didn't put the platform up after I got the first resident out and took them back to their room. I went back and went through the door to get (Resident #216). When asked what they meant when they said door, CNA G indicated they went through the side entrance door of the van. CNA G revealed they proceeded to unhook Resident #216's wheelchair after they reentered the van through the side door and stated, I backed them out the back. In my head, the platform was up. CNA G continued, I didn't even look, I was just backing up. The next thing I knew, I was on the ground and the wheelchair and (Resident #216) and the oxygen were on top of me. CNA G verbalized they pushed the Resident off of them after they fell. CNA G was asked what time it happened and replied, It was close to 4:30 PM. CNA G stated, I believe it was the receptionist who came out and found us on the ground. CNA G indicated they believed Staff V called for help. CNA G stated, We had nurses and aides out there too and then they brought (Resident #216) in and assessed them. CNA G relayed the Resident was then transported to the hospital. When asked how far they fell, CNA G replied, I believe it was a two-foot drop. When asked if they received any education and/or disciplinary actions following the occurrence, CNA G revealed they do not drive anymore. CNA G was asked if the Resident was injured and stated, (Resident #216) broke their neck. They already had a fracture. CNA G revealed they had no injuries, other than being sore, following the incident. An interview was completed with Resident #216's Family Member AA on 3/20/24 at 2:30 PM. When queried regarding the incident involving Resident #216 and the transportation van on 6/7/23, Family AA stated, (Resident #216) fractured the vertebrae in their neck and got stitches in their toe. Family AA stated, (Resident #216) wasn't being taken care of (at facility) and fell out (of the van) backwards. When asked if they were informed of what had occurred by the facility, Family AA revealed a facility nurse contacted them and informed them the Resident had fallen from the van during removal and had been sent to the hospital. Family AA indicated they did not realize what actually happened until they got to the hospital. When queried what happened at the hospital, Family AA revealed Resident #216 had to be transferred from the local hospital to a larger hospital. When asked why the Resident was transferred, Family AA revealed the Resident needed to see a specialist for their neck and was at the larger hospital for a week or two. Family AA specified the fracture could have been prevented if facility staff would have done what they were supposed to do. On 3/21/24 at 8:33 AM, an observation of the transportation van was completed. A measurement of the back of the van to the group revealed the distance was 28 inches. An interview was conducted with the Director of Nursing (DON) on 3/21/24 at 8:43 AM. When queried regarding facility investigation completion, the DON revealed the Administrator had completed the investigation. The Administrator was out of state and unavailable. When queried regarding other Residents in the van, the DON stated, I didn't know there was anyone else. When asked if the facility had documentation of demonstration and check offs of van transportation for loading and unloading residents for CNA G the DON stated, No check offs. The transportation schedule for Residents on 6/7/23 was requested at this time. At 8:50 AM on 3/21/24, the DON approached this Surveyor and stated there was one other Resident who had been transported on the day of the incident, but they had been removed from the van prior to the fall. When queried regarding CNA G stating there had been three residents, the DON indicated they just spoke to CNA G and confirmed there were only two residents. A follow up interview was completed with CNA G on 3/21/24 at 8:57 AM. When asked if there were two or three residents in the transportation van on 6/7/23 when the incident occurred involving Resident #216, CNA G stated there was (discharged Resident #1) and then I had to pick up (discharged Resident #2). CNA G stated, I wasn't expecting to pick up (discharged Resident #2) so I got (discharged Resident #1) out of their wheelchair and sat them on the seat. When asked what they did with the wheelchair, CNA G revealed they folded it up. When queried why they told the DON there were only two residents in the transportation van, CNA G indicated they had forgot. Review of CNA G's education and training completion documentation prior to 6/7/23 revealed no documentation of van lift use and competency. An interview was completed with Staff V on 3/21/24 at 9:20 AM. When queried if they were working on 6/7/23, Staff V confirmed they were. When asked what happened, Staff V stated, I saw (CNA G) pull in. It was such a traumatic thing. Upon request, Staff V was provided a copy of their witness statement for review. Staff V then stated, (CNA G) got the one (resident) off and I wheeled them where they needed to go. When asked, Staff V was unable to recall the name of the resident they took into the facility. When queried what time it was, Staff V stated, It had to be right around 4:30 PM because that is when I leave. Staff V revealed they went back out to see if CNA G needed more help before they left for the day and stated, As soon as I walked out, I seen them on the ground. I ran back in and hollered for help. When asked, Staff V revealed they were going back to see if CNA G needed more help before they left for the day. When asked what they observed when they exited the building, Staff V stated, (CNA G) was on their back on the ground and the Resident was on the ground next to them on their back. When asked where Resident #216's wheelchair was, Staff V revealed they did not recall seeing the wheelchair. When asked, Staff V stated both CNA G and Resident #216 were on the concrete outside of the building on their backs with the Resident closest to the door. Staff V was asked if either the Resident or CNA G were touching the platform that raises and lowers and stated It (platform) was flat. When asked what they meant, Staff V stated, It was parallel with the van exit, like it was never lowered. Staff V continued, The back of the platform had the lip, (CNA G) may have tripped and pulled (Resident #216) down. When asked, Staff V reiterated they were certain the platform was up and parallel with the back of the van. Staff V was asked to draw a picture. The picture showed both CNA V and Resident #216 past the end of the raised platform on the concrete with Resident #216 closest to the door of the facility. Staff V then stated, Both of them hit their heads. When queried regarding Resident #216, Staff V stated, The Resident was moaning and was obviously in a lot of pain. Staff V revealed CNA G was more concerned about the Resident. Staff V was asked what happened next and stated, (LPN Z) and (CNA X) came out. I think (CNA X) seen from a Resident room. At 9:36 AM on 3/21/24, Staff V re-entered the conference room and indicated they made a mistake during their previous interview. When asked what they meant, Staff V stated, It (platform) was down, not up. When asked, Staff V stated both the Resident and CNA G were on the concrete past the end of the platform on their backs. No further explanation and/or description was provided when asked. An interview was completed with LPN Z on 3/21/24 at 9:41 AM. When queried if they were working on 6/7/23, LPN Z replied that they were. LPN Z was asked if they recalled the incident involving Resident #216 and the transport van on that day, LPN Z stated, I know (Resident #216) had an appointment and (CNA G) had taken them. LPN Z stated the receptionist had yelled for help and they responded along with other staff. When queried what they observed, LPN Z stated, (Resident #216) was on the ground and revealed there were multiple people outside at that time. LPN Z stated, Somebody got the Hoyer and indicated the Resident was placed in their wheelchair using the lift. When queried who got the Resident off the ground and into the wheelchair using the Hoyer lift, LPN Z replied, The aides (CNAs). When queried if they had completed an assessment of the Resident, LPN Z replied, (RN W) would have done an assessment. LPN Z was then asked where Resident #216's oxygen tank and wheelchair were at when they observed the Resident and stated, on the ground next to them. When asked the position of the platform, LPN Z indicated it was down. On 3/21/24 at 10:03 AM, an interview was completed with CNA X. When queried regarding the incident on 6/7/23 involving Resident #216 and the transport van, CNA X revealed they did not see it happen and stated, A resident alerted me to them being on the ground. CNA X indicated they looked out the window and both CNA G and Resident #216 were on the ground and the wheelchair was tipped sideways. CNA X stated, I went out and by the time I got there, (CNA G) was up. When asked what happened next, CNA X stated, We had to grab the Hoyer to get (Resident #216) up. When queried if Resident #216 was in pain, CNA X stated, Oh yeah. CNA G was asked who transferred the Resident in the Hoyer lift and revealed it was the CNA staff but was unable to recall staff names. When asked how they got the Resident into the sling, CNA X replied, We had to roll (Resident #216). When queried if Resident #216 expressed pain and/or discomfort when being rolled and transferred in the Hoyer, CNA X replied, Yeah and stated Resident #216 was grimacing. CNA X was asked if anyone braced and/or supported the Resident's head and neck when the Resident was being rolling and transferred in the Hoyer, CNA X replied, Not that I remember. At 10:13 AM on 3/21/24, an interview was completed with the DON. When asked, the DON revealed the facility has some video camera surveillance. When queried regarding footage of the incident involving Resident #216 and the transport van on 6/7/23, the DON stated there were no cameras in the front of the building and no footage of the incident. An interview was conducted with RN W on 3/21/24 at 12:07 PM. When queried what occurred on 6/7/23 involving Resident #216, RN W stated, I was called up front because an employee and Resident on the ground. RN W then stated, I knew the Resident was hurt pretty bad. We sent them out to the hospital, and they never came back. When asked how the Resident was hurt pretty bad, RN W replied, Lacerations and pain. When asked Resident #216 was bleeding, RN W stated, Yes. I can't remember if the laceration was on their head, and they had pain. When queried if they assessed the Resident when they were outside, RN W revealed they listened to their lungs, got vital signs, and asked where hurt. When asked if the Resident was having pain, RN W indicated they were and stated, (Resident #216) was a tough person and didn't like to complain. When asked what they did next, RN W stated, Hoyered (Resident #216) up and took them to their room and did a more thorough assessment. When queried if the Resident's neck was immobilized prior to moving the Resident, RN W stated, I don't think so. RN W was asked if they considered applying a cervical collar (c-collar) for immobilization and replied, We don't have c-collars. When asked if they considered using a backboard, rather than the Hoyer lift, to transfer the Resident due to the mechanism of the fall and potential extent of injuries, RN W stated, I don't think we even have one. When asked why they did not call EMS immediately, when the Resident was outside rather than moving them, RN W stated, I don't know. We had to get (Resident #216) inside to assess them. When queried regarding the location of the wheelchair and the oxygen tank, RN W indicated they did not know and stated, I don't know if (Resident#216) was in the wheelchair originally. When asked what they meant, RN W revealed they did not know if the Resident was seated in their wheelchair when they fell out of the transport van. When queried regarding the Resident's position when they first saw them, RN W stated, Think maybe (Resident #216) was sitting but I'm not sure. On 3/21/24 at 12:26 PM, an interview was conducted with the DON. The DON was asked what their expectations of nursing staff in response to an incident when a resident is pulled out of a wheelchair van backwards directly onto the pavement and stated, A full head to toe (assessment), vital signs, neuros. When queried why Resident #216 was moved and transferred using a Hoyer lift without cervical spine immobilization, the DON stated, (Resident #216) didn't complain of pain right away. The DON was then asked why documentation specified the Resident complained of generalized and severe pain neck, head and shoulders but did not indicate the Resident had no pain initially and did not provide an explanation. When queried why the Resident was transferred using a Hoyer lift and without cervical spinal immobilization, the DON stated, That is the standard. When asked what they meant, the DON revealed it was the standard to use a Hoyer lift for a Resident who fell. When queried if being pulled out of a wheelchair van backwards in a wheelchair onto the concrete/pavement was a typical mechanism of injury for a fall, the DON confirmed it was not. The DON was then asked if the facility had cervical spinal immobilizers (c-collars) and stated, No. When asked why Resident #216 was moved, when the facility did not have the equipment to provide cervical spinal immobilization, and the SBAR assessment specified Resident #216 was having severe pain, the DON stated, I was not there. The DON indicated the Resident was transferred to the hospital in a timely manner. When queried if the Resident was transferred from the ground to a wheelchair using a Hoyer lift and then from the wheelchair to their bed, the DON confirmed and asked, Would a couple of minutes make a difference? When queried regarding cervical spinal immobilization, the DON stated, Yes, I agree the movement may have made a difference. Review of EMS documentation revealed dated 5/7/23 reviewed EMS was called at 5:00 PM by the facility for a fall at the facility. The EMS report detailed, Primary Impression: Multiple injuries . Fall with injury . Distress: Moderate Fall . 2 feet . Mechanism of Injury: Blunt . Trauma . Assessment Time: 5:06 PM . Narrative: Dispatched for a fall . Arrived to find (Resident #216) sitting on edge of bed. Staff on scene states that (Resident) was being taken out of the wheelchair van on the lift when they fell off the lift approximately 2 feet up . fell on another employee . States has laceration on foot . Goose egg noted to right side of head. Swelling and pain to left upper arm . bruising noted to both legs, hands, and feet. 4 cm (centimeter) laceration to right foot, toenail ripped off big toe on left foot . A second EMS report was received and revealed Resident #216 was transferred from the local hospital to a tertiary hospital for specialty services on 6/8/24 at 2:45 AM. Review of Resident #216's hospital documentation revealed the following: - 6/7/23 at 5:39 PM: ED Provider Notes . Review of Systems . Musculoskeletal: Positive for back pain and neck pain. Skin: Positive for wound . Laceration to right great toe, multiple abrasions to hands and feet . Positive for headaches . C-Collar has been applied. Does have pain with palpation. There is ecchymosis and point tenderness noted approximate T1 (First Thoracic Spine Vertebra) . Comments . There are multiple abrasions noted to the dorsal surface of toes and fingers. There is a laceration noted to the dorsal surface of great toe that will require repair . Patient has history of dementia and is a poor historian . alert to person and place . does recall the fall . Laceration Repair . Laceration details: Location . R big toe. Length (cm): 3 . Depth (mm): 3 . Repair method: Sutures . Medical Decision Making: Patient has been seen and evaluated in the emergency department for a fall . out of a van from the floor level onto the ground . did sustain a C2 (Second Cervical Spinal Vertebra) fracture . also has multiple abrasions noted to hands and feet . right great toe laceration requiring repair . I did speak with the radiologist regarding CT (Computed Tomography scan) of the C-spine as has had previous neck fracture in the past. This is a new fracture when compared to most recent CT. I did speak with (Specialist Physician) at (Tertiary hospital) and the patient will be transferred as a trauma for further evaluation and treatment . - 6/7/23 at 5:49 PM: ED Triage Notes (Nursing) . Patient fell at (facility). Ems states patient fell forward out of wheelchair onto a staff member. Patient did hit head . L arm pain, laceration to R foot and part of L great toenail removed in fall . - 6/7/23, Resulted 10:35 PM: CT cervical spine without contrast (trauma age >65) . There is a new tip of C2 spinous process fracture with 3 mm of distraction of the tip fragments . Final Result . 1. New tip of C2 spinous process fracture . - 6/7/23, Resulted 10:24 PM: CT head without contrast .Head trauma, moderate-severe . There is a right posterolateral frontal scalp hematoma . Final Result . Right lateral scalp hematoma . Review of facility policy/procedure entitled, Patient Transport Van: Safety Policy (no date) did not include any information pertaining to loading and/or unloading residents utilizing the wheelchair platform.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) prevention and management and care, including timely and appropriate wound identification for four residents (Resident #22, Resident #23, Resident #30, and Resident #37) of seven residents reviewed, resulting in a lack of proper identification and care of Resident #22's and Resident #23's pressure ulcers, Resident #30 developing an unstageable Deep Tissue Injury (DTI- area of damage to underlying tissue with unknown depth) pressure ulcer, and Resident #37 developing a DTI pressure ulcer, unnecessary pain, and the likelihood for further pressure ulcer development and a decline in overall condition. Findings include: Resident #23: On 3/19/24 at 3:57 PM, an interview was conducted with Certified Nursing Assistant (CNA) O. When queried regarding Residents with pressure ulcers and/or wounds, CNA O stated, (Resident #23) has something. With further inquiry, CAN's O indicated they were unsure what type of wound the Resident had. On 3/19/24 at 4:00 PM, an observation occurred of Resident #23 in their room. The room was dark with the lights off. The Resident was in bed, positioned on their back, wearing a hospital style gown The Resident's eyes were open. Resident #23 made eye contact when spoke to but provided non-sensical responses to questions. An alternating air mattress was noted on the bed. An interview was conducted with CAN's T on 3/20/24 at 8:39 AM. When queried regarding residents with pressure ulcers, CAN's T stated, (Resident #23) had open sores on their bottom. When asked if the wounds were caused from pressure, CAN's T indicated they were. Record review revealed Resident #23 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included right sided hemiplegia and hemiparesis (one sided paralysis), dysphagia (difficulty swallowing), and aphasia (difficulty to use or comprehend language) following cerebral infarction (stroke), weakness, falls, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and was dependent upon staff for completion of all Activities of Daily Living (ADL's) with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development, did not have any pressure ulcers, but did have Moisture Associated Skin Damage (MASD) at the time of assessment completion. The Review of Resident #23's care plans revealed a care plan entitled, (Resident #23) has actual impairment to skin integrity AEB (As Evidenced By): MASD (Moisture-Associated Skin Damage) right and left buttock (Initiated: 2/1/24). The care plan was changed on 2/1/24 from, (Resident #23) actual impairment to skin integrity AEB: Stage 2 pressure ulcer right buttock. Review of Resident #23's care plans revealed the Resident had a care plan titled, (Resident #23) has actual impairment to skin integrity AEB: Stage 2 pressure ulcer right buttock which was changed on 2/1/24 to (Resident #23) has actual impairment to skin integrity AEB (As Evidenced By): MASD (Moisture-Associated Skin Damage) right and left buttock (Initiated: 2/1/24). The care plan included the following interventions: - Evaluate and treat per physician's orders (Initiated: 2/13/24) - Apply barrier cream per facility protocol to help protect skin from excess moisture (Initiated: 2/13/24) - Educate resident/family/caregivers of causative factors and measures to prevent skin injury (Initiated: 2/13/24) - Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 2/13/24) - Identify/document potential causative factors and eliminate/resolve where possible (Initiated: 2/13/24) - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal . to MD (Initiated: 2/13/24) On 3/20/24 at 8:45 AM, Resident #23 was observed sitting in a wheelchair in their room. Resident #23 made eye contact and made non-sensical verbal responses when spoke to. When asked if they were able to move their legs, Resident #23 did not move their legs and shook their head to indicate no. Review of Resident #23's Wound Evaluation and wound image documentation in the EMR revealed an assessment dated [DATE] at 2:21 PM. The evaluation detailed, MASD . Right Gluteus - Medial . Deteriorating - 9 months old . In-House Acquired . Length: 2.47 cm . Width: 0.93 cm . Wound Bed . Granulation . Exudate . Light . Serosanguineous . Edges . Non-attached . The attached wound picture with measuring sticker was noted to be off center in the image. The wound was oval shaped with distinct edges and visible depth. The wound bed in the image was light pink and red in color with white tissue at the 12 and 5 o'clock positions. The initial date of the wound specifically identified and unable to be determined and a review of progress note documentation was completed. The following documentation was present in Resident #23's EMR: - 3/13/24 at 9:27 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 (Zero) . Skin turgor with good elasticity . Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. Continues with treatment to buttocks. - 3/6/24 at 9:28 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 (Zero) . Skin turgor with good elasticity . Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. - 2/15/2024 15:23 Type: *IDT . Residents MASD wounds on buttocks are worsening at this time. Resident will be started on pro-stat (nutritional supplement for individuals with increased protein needs, malnutrition, and pressure ulcers) per (physician) and resident will be encouraged to lay down between meals at this time. Treatment orders will continue to be the same . - 2/1/24 at 3:12 PM: Nursing Evaluation . skin integrity concerns. 0 (zero) . - 1/18/24 at 3:23 PM: IDT . Wound is almost healed, will continue to monitor weekly at this time. No further concerns . - 11/26/23 at 12:58 AM: Skin/Wound Note (Narrative) . Upon rounding on resident and changing hydrocolloid dressing (wound care dressing used for mildly exudating wounds to provide a moist wound healing environment) 2 more areas of open skin noted next to current open area on right buttock. Dressing increased to larger size . - 10/29/23 at 5:37 PM: Nursing Evaluation Quarterly assessment . Skin Integrity: The resident does not have skin integrity concerns . Resident get excoriation to buttock due to incontinence, ointment applied as preventive . - 9/29/23 at 2:56 PM: IDT (Interdisciplinary Team) . MASD noted to R buttock, wound previously closed, continues with incontinence, and wound has opened back up. Surrounding wound is boggy and white/purple . - 9/27/23 at 12:16 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 . L (left) buttock: open area 0.5 cm in length, 0.2 cm wide, slough noted in wound bed, area cleansed, and current treatments applied. - 8/23/23 at 1:28 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 . Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. Left buttock open area has healed to small pin-like open area, cream applied. - 8/15/23 10:50 AM: Skin/Wound Note (Narrative) LATE ENTRY . wound NP (Nurse Practitioner) in facility this day and resolved buttock wound . - 7/29/23 at 4:47 PM: Nursing Evaluation . Skin Integrity: The resident has skin integrity concerns. 0 (zero) . - 7/26/23 at 3:13 PM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0 . Skin moisture is normal. Skin condition is normal. Continue to apply cream to buttocks . - 7/19/23 at 3:24 AM: Skin Observation . Resident has NEW skin issue(s) observed. 1 . Small open areas on bilateral inner buttocks . Skin moisture is normal. Skin condition is normal . - 3/20/23 at 9:26 PM: Physician . Progress Note . Right gluteal wound Stage III. Skin Intact . - 3/2/23 at 3:15 PM: Physician . Progress Note . Right gluteal wound . Stage III (open wound with full thickness tissue loss). 3.0 (cm) x 1.0 (cm) . Authored by Wound Care Physician. An interview was completed with Registered Nurse (RN) J on 3/20/24 at 11:10 AM. When queried if the facility had a wound care nurse, RN J revealed they did not. When queried regarding Resident #23's wound, RN J stated, I believe (Licensed Practical Nurse [LPN] R) is doing that today. On 3/20/24 at 11:13 AM, an interview was completed with LPN R. When queried regarding Resident #23's wound care treatment, LPN R confirmed they were completing wound care measurements and treatments. A request to observe Resident #23's wound was completed at this time. On 3/21/24 at 10:22 AM, Resident #23 was observed sitting in their wheelchair in the Activity room of the facility. On 3/21/24 at 3:12 PM, an observation of Resident #23's wound was completed with LPN R. The Resident was in bed and positioned on their side. The wound bed was elongated and slightly larger than a half dollar. The wound had visible depth and defined borders. The wound bed was pink and red with white colored tissue on the lateral side, from approximately 12 o'clock to 4 o'clock. The wound was noted to be located over the bony prominence of the ischial tuberosity (bony prominence in lower pelvis) on the right gluteus. The periwound was discolored and darkened with a reddened area proximal to the open wound. An interview was conducted with LPN R following the wound care observation. When queried why the wound was not classified as a pressure ulcer, LPN R replied the wound had been there was a long time and had opened and closed. LPN R then stated the wound had recently deteriorated and a new treatment had been ordered. When asked if an area could begin as MASD and then become a pressure ulcer, LPN R stated it could. LPN R was asked if the wound was over a bony prominence and had defined borders and confirmed it was. LPN R was asked again how the wound was not a pressure ulcer and replied, It could be. When queried why there were no depth measurements of the wound documented, LPN R revealed the facility utilizes the wound imaging system for wounds and it does not measure wound depth. No further explanation was provided. Resident #30: On 3/19/24 at 3:57 PM, an interview was conducted with Certified Nursing Assistant (CAN's) O. When queried regarding Residents with pressure ulcers, CAN's O stated, (Resident #30) has something on their heel. With further inquiry, CAN's O revealed the area on their heel was black from the Resident's heel dragging when they were in their wheelchair. When asked if the Resident was able to move both of their legs, CAN's O revealed the Resident had a stroke which affected their left side. When queried how the Resident's foot was dragged, CAN's O specified the Resident did not usually have foot pedals in place on their wheelchair. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included depression, Chronic Obstructive Pulmonary Disease (COPD), heart failure, and hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, had one sided upper and lower extremity impaired Range of Motion (ROM), and required substantial to total assistance to complete Activities of Daily Living (ADL's). The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers at the time of assessment completion. Review of Resident #30's Electronic Medical Record (EMR) revealed the Resident had a care plan entitled, The resident has potential for impairment to skin integrity r/t (related to) diabetes, obesity, impaired mobility, neuropathy (Initiated: 4/3/23). The care plan included the interventions: - Apply barrier cream per facility protocol to help protect skin from excess moisture (Initiated: 4/10/23) - Encourage that heels are elevated while resident is lying in bed . (Initiated: 4/10/23) - Change bedding/clothing if moist (Initiated: 7/18/23) - Dietary Consult as needed (Initiated: 4/10/23) - Encourage/assist with turning and repositioning (Initiated: 4/10/23) - Monitor skin when providing cares, notify nurse of any changes in skin appearance (Initiated: 4/10/23) The Resident did not have a care plan in place related to a current pressure ulcer/alteration in skin integrity. Further review of Resident #30's EMR revealed the Resident had a pressure ulcer on the left heel in May 2023 which had healed. Review of documentation in Resident #30's EMR revealed the following: - 3/13/24 at 9:37 AM: Skin Observation . Resident has NO NEW skin issue(s) observed. 0. Skin turgor with good elasticity. Skin color is normal for ethnic group. Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. - 3/15/24 at 3:10 PM: Health Status Note . left heel is redden (sic) and soft, comfort foam applied for cushioning. Res to wear heel boots at all times. (Spouse) notified, voiced concern that heel has opened many times when resident walks even short distances. Resident #30's EMR did not contain wound assessment documentation. Review of Resident #30's health care provider orders revealed the Resident did not have an active order for heel boots. On 3/20/24 at 11:54 AM, Resident #30 was observed being pushed down the hallway of the facility in their wheelchair by Therapy Staff N toward the dining room. The Resident had a soft heel boot in place on their left foot and a regular foot covering in place on their right foot. After taking Resident #30 into the dining room, an interview was completed with Therapy Staff N. When queried why Resident #30 had a heel boot in place on their left foot, Therapy Staff N stated, I'm not sure. Therapy Staff revealed the Resident's foot is a bit internally rotated and indicated the heel boot may be related to that. On 3/20/24 at 4:40 PM, an interview was completed with CAN's Q. When queried regarding observation of Resident #30 with a heel boot in place on their left foot only, CAN's Q replied, Supposed to have a bandage on heel. When asked the reason for the bandage, CAN's Q indicated they were not sure. An interview was completed with Unit Manager Licensed Practical Nurse (LPN) R on 3/20/24 at 4:41 PM. When queried regarding Resident #30's left heel, LPN R stated, I wasn't here and revealed they were unaware of any concerns regarding the Resident's heel. When queried regarding the progress note dated 3/15/4 in Resident #30's EMR, LPN R reviewed the progress note documentation. When queried if there was any documentation after the note on 3/15/24, LPN R confirmed there was no additional assessment documentation. Upon request, an observation of Resident #30's left heel was completed with LPN R at this time. Upon entering Resident #30's room, the Resident was observed sitting in a wheelchair in their room with their feet directly on the floor. When queried regarding their left heel, Resident #30 stated it hurt. When asked how long it had been hurting, Resident #30 replied, About a week. LPN R removed the heel boot and sock on Resident #30's left foot. There was no bandage in place over the Resident's heel. The medial edge of the heel was dark red in color with a deep, dark, purplish colored area, slightly larger than a dime was present in the center of the dark red area. When queried if the dark red area was blanchable, LPN R proceeded to press on the area and stated, No. Following the wound care observation, LPN R was queried regarding the wound and stated that it was an unstageable pressure ulcer. When queried regarding the facility policy/procedure related to notification of alteration in skin integrity and implementation of treatments/interventions, LPN R stated, Usually reported to the Unit Manager and then the DON (Director of Nursing). LPN R then stated, Was supposed to have a foam cushion in it and did not have it. When queried regarding staff statements related to the pressure ulcer, LPN R did not provide an explanation. When queried if Resident #30 had an order in place for the heel boot, LPN R confirmed there was no order for the heel boots. The DON entered LPN R's office at this time. When queried regarding the unstageable pressure ulcer on Resident #30's heel, the DON stated, It wasn't brought to my attention. After reviewing Resident #30's EMR, the DON stated, I do remember talking about this on Friday and indicated they did not see the area the nurse had identified on Resident #30's left heel and planned to follow up, but had not. When queried why there was no follow up assessment documentation of the pressure ulcer, the DON revealed there should have been. No further explanation was provided. Record review of the facility 'Skin Protection Guideline', dated 7/7/2021, the purpose was to provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown. here was no mention of 'Moisture Associated Skin Damage' within the facility skin management procedure. Record review of the National Pressure Injury Advisor Panel (NPIAP) staging tool (undated) revealed that there was no mention of a Moisture Associated Skin Damage. Resident #22: Observation on 03/19/24 at 10:54 AM of Resident #22 lying in bed on his back with the head of the bed elevated estimated above 30-degree angle, Resident appears asleep. Roommate is awake and stated he doesn't roll over, that's how he sleeps on his back. In an observation on 03/19/24 04:32 PM the state surveyor observed Resident #22 to be ambulating in the main hallway with gray sweat pants on and what appeared to be 2-3 red spots noted on the back of the pants on lower aspect of the buttock region. Record review of Resident #22's OBRA quarterly Minimum Data Set (MDS) dated [DATE] revealed a younger special-needs gentleman who admitted to the facility on [DATE]. Record review of Resident #22's electronic medical record revealed a skin/wound evaluation dated 3/19/2024 at 11:07 AM and noted right ischial tuberosity wound in-house acquired measurements: length 0.81cm X width 0.79cm. Review of the percent-changed graph noted the wound started on 8/1/2023. Record review of left ischial tuberosity in-house acquired evaluation dated 3/6/2024 developed over a year prior, measurements: length 2.72cm X width 1.27cm. Observation on 03/20/24 at 08:31 AM with Certified Nurse Assistant L, who had just given Resident #22 a morning shower, revealed there were observed 4 open areas, with bleeding. Observation of the 4 open wound areas revealed red beefy tissue with depth noted. Resident #22 was asked if the 4 open wounds were painful, and he shook his head up and down for yes. In an observation on 03/20/24 at 08:35 AM, Registered Nurse (RN)/infection control/Unit manager E came into the shower room on the west unit to assess the wounds of Resident #22. RN E applied calaseptine cream to all open areas. RN E stated that the facility called the wounds moisture associated skin damage. Resident #37: Record review of Resident #37's quarterly Minimum Data Set (MDS) dated [DATE] revealed section M: skin conditions revealed that the resident #37 was admitted with one unstageable pressure injury and also developed another unstageable pressure injury while residing at the facility. In an interview on 03/19/24 at 03:33 PM with Resident #37 revealed that she did have bilateral heel pressure injuries. Resident #37 stated that she was in the hospital and the right heel sore just showed up. Then she came back to the facility and a while later (months) after being back at the facility the left heel got a sore also. Resident #37 stated that she was so sick during the time that they just didn't keep the feet off the mattress. Resident #37 stated that she does get wound clinic treatments for the heel wounds. Record review of Resident #37's left heel pressure injury in-house acquired evaluation, dated 3/13/2024, revealed the area of the left heel pressure injury status as deteriorating and over 7 months old. Measurements: length 3.78cm X width 2.38cm, no depth measurements were taken. Area measurement of 6.83cm covered most of the left heel. Record review of Resident #37's 'Skin & Wound Evaluation' form dated 3/20/2024 at 12:02 PM revealed pressure staged as deep tissue injury and in-house acquired, measuring 8.5cm area, length 3.6cm X width 3.1cm. No depth was measured. Progress was noted as stalled. Observation and interview on 03/20/24 at 08:16 AM with the Registered Nurse/Unit manager (RN/UM) E the surveyor Observation of bilateral heels had a plain gauze dressing wrapped in white Kerlix gauze and taped. The old dressing was removed and observation of the right heel being black in color. Observation of the left facility acquired pressure injury revealed the left heel had drainage noted to the old dressing which was removed. RN E applied wound cleanser with 4 x 4 gauze and then patted dry. RN E then applied Dermacal (treatment) to wound bed, cut to size, and covered with 4 x 4 gauze, Resident #37 stated that she went to the wound clinic last Tuesday 3/12/24. RN E stated that the dressing was removed the day prior by the Director of Nursing who took it off yesterday and did not apply the complete dressing. RN E proceeded to apply the Unna boot with Zinc and calamine 3inX10yards. that is changed one time weekly. This dressing was not in place at the beginning of the wound observation. In an interview on 03/20/24 at 08:16 AM, during the bilateral heel dressing changes Resident #37 revealed that she stated she got the wounds from lying in bed and goes to the wound clinic now. Resident #37 stated she got the wounds from here (facility), they just showed up. Resident #37 stated that the wounds are painful. At the pain clinic they debride/scrape them, and it hurts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #40: Record review revealed that resident #40 is [AGE] years old, admitted on [DATE], currently on hospice, has a brief interview for mental status (BIMS) of a 6 indicating severe impairment. Resident #40 has diagnoses of chronic obstructive pulmonary disease (COPD), gait abnormalities, lack of coordination, repeated falls, unsteady on feet, major depressive disorder and anxiety disorder. On 03/20/24 at 12:53 PM, record review of resident #40's fall reports revealed that resident #40 sustained falls on 4/19/23, 7/10/23, 7/12/23, 7/28/23, 7/30/23, 8/9/23, 8/14/23, 11/17/23 and 3/4/24. Eight of these falls were unwitnessed. Fall sustained on 7/10/23, resident #40 was observed on the floor in their room, resident #40 had self transferred, the fall was unwitnessed. Care plan interventions included a medication review and to use call light. BIMS was 10 indicating moderate impairment. Fall sustained on 7/12/23, unwitnessed fall in the room, resident #40 observed on the floor on their left side about two feet from the entrance door, spilled water was observed on the floor. Fall report indicated that Resident #40 stated they had been reaching for water, slid out of bed and scooted over to the door. Care plan interventions included: offer to take resident to the bathroom two times a night. Fall sustained on 7/28/23, this was an unwitnessed fall, resident #40 was observed on the floor in the bathroom, stated they hit head on the trash can. Care plan interventions included: post fall med review, take to the restroom after meals, grippy socks. Fall sustained on 7/30/23, this was an unwitnessed fall, resident #40 was observed lying on her right side, head under the sink, legs bent at the knees, feet towards the bed. resident #40 stated they hit the right side of their head, unsure of what they hit it on. Resident #40 complained of sharp pain with any movement of their right arm. Resident sustained a right clavicle fracture. The family was notified of the fall, the physician was notified of the fall and resident #40 was sent to the emergency room for evaluation and treatment. Care plan interventions: education on using call light to ask for assistance. BIMS 10, moderate impairment. Fall sustained on 8/9/23, this was an unwitnessed fall, resident #40's roommate called the certified nursing assistant (CAN's) to the room, resident #40 was observed on the floor mat next to their bed, fall report indicated that resident #40 stated they tried to get out of bed to go to the bathroom. No injury. The fall was unwitnessed. Care plan interventions included: perform a medication review. Fall sustained on 8/14/23, resident #40's roommate came to nurses station reporting that resident #40 is on the floor. This was an unwitnessed fall. Resident #40 noted to be sitting next to the bed on the floor mat, denies hitting head, resident #40 stated they couldn't find their call light because it was attached to their blankets and got twisted up. No injury noted. No neuro assessments. Care plan intervention to put the call light on the bed and not the blankets to avoid this happening again. BIMS of 4. Fall sustained on 11/17/23 fall report indicated that resident #40's anti-roll back brakes failed on the wheelchair during self transfer and resulted in a fall. This was an unwitnessed fall. Care plan interventions included repairing the anti-roll back brakes. Fall sustained on 3/4/24, this was an unwitnessed fall, resident #40 noted to be kneeling in her room between bed and wheelchair. Resident #40 had vomited and attempted self transfer from the wheelchair to the bed. Fall report indicated that resident #40 had been complaining of nausea the previous shift, a new order for zofran as needed was put in place. No injuries noted, BIMS 6. On 03/21/24 at 09:32 AM, record review of resident #40's care plan revealed resident was a 1-2 staff assist with transfers. On 03/21/24 at 09:45 AM, an interview was conducted with the Director of Nursing (DON), the DON was asked how much assistance did resident #40 need to ambulate. The DON stated that resident #40 was a 1 assist for ambulation, meaning they needed one staff assistance to ambulate. The DON was asked if resident #40 had a history of self transferring and the DON said yes resident #40 does self transfer. The DON stated that up until the time of the fall with fracture on 7/30/23 the resident had been successful with self transfers from the bed to the chair. DON stated that at times resident #40 would attempt to ambulate but staff would get to resident #40 before they got into the hallway. On 03/21/24 at 09:55 AM, an interview was attempted resident #40, resident #40 could not recall the fall that occurred on 07/30/23 that resulted in a fracture. Resident #40 is currently on hospice and declining. Residents #40's BIMS is currently 6 indicating severe impairment and BIMS at the time of the fall was 10 indicating moderate impairment. On 03/21/24 at 10:10 AM, an interview was conducted with the director of therapy, The therapy director was asked what the residents ambulation and transfer status at the time of discharge from therapy. The therapy director stated that when resident #40 was on therapy they were a standby/supervision for ambulation and supervision/touching assistance for transfers from bed to chair/chair to bed. On 4/26/23 resident #40 was discharged from therapy and she was standby/supervision assist for ambulation with a walker and supervision with transfers. On 03/21/24 record review of Physical Therapy discharge notes for resident #40 revealed that they were supervision/touching assistance for transfers from bed to chair and chair to bed. Discharge notes also revealed that resident #40 is a supervision/touching assistance for ambulation. Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures to ensure adequate supervision for fall prevention and management for three residents (Resident #18, Resident #36, and Resident #40) of eight residents reviewed, resulting in a lack of implementation of meaningful interventions to prevent falls, Resident #36 and Resident #40 experiencing multiple falls including falls with fracture, emergency medical treatment, unnecessary pain, and the likelihood for decline in overall health. Findings include: Resident #18: On 3/19/24 at 11:10 AM, Resident #18 was observed sitting in their room in a Broda chair (wheeled, reclining chair with head rests and elevating solid leg rests used for positioning). A Hoyer (mechanical lift) sling was under them, and their call light was not within reach. The Resident was noted to have upper and lower extremity contractures. An interview was completed at this time. When queried if they had fallen in the facility, Resident #18 indicated they had but did not provide further details. When asked when they fell, Resident #18 smiled but not provide a verbal response. On 3/20/24 at 2:01 PM, Resident #18 was observed in their room. The Resident was in bed, positioned on their back with their eyes closed. The left side of the Resident's bed was against the wall and a wedge style cushion was in place under the fitted sheet. Review of the CMS-802 Form indicated Resident #18 had not fallen at the facility. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Central Pontine Myelinolysis (CPM- neurological disorder which causes destruction of the substance which protects nerve fibers), heart disease, Tourette's disorder, bipolar disorder, pain, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, had impaired mobility in both upper and lower extremities, and was dependent upon staff to complete all Activities of Daily Living (ADL's) including turning and repositioning. The MDS revealed the Resident had no falls. Review of Resident #18's Electronic Medical Record (EMR) revealed a care plan entitled, The resident is high risk for falls r/t (related to) debility (Initiated: 6/5/23). The care plan included the interventions: - Ensure bed brakes are locked (Initiated: 12/14/23) - Anticipate and meet the resident's needs (Initiated: 6/5/23) - Follow facility fall protocol (Initiated: 12/14/23) A second care plan entitled, The resident has had an actual fall . (Initiated: 8/2/23) was noted and included the following intervention, Date and description of other interventions put in place after a fall: 8/1/23: Neuros per protocol, low bed, mats on floor while in bed; 2/28/24: Bed rotated as resident prefers to roll onto R. side (Initiated: 8/2/23) The care plan entitled, The resident has an alteration in musculoskeletal status r/t BLE (Bilateral Lower Extremity) and BUE (Bilateral Upper Extremity) contractures (Initiated: 11/20/23) included the intervention, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance (Initiated: 11/20/23). Review of Resident #18's EMR revealed the Resident was assessed to be a high risk for falls on 6/5/23, 8/1/23, 11/1/23, 2/9/24, and 2/28/24. Progress note documentation detailed: - 8/1/23 at 9:30 PM: Post-Fall Evaluation . New pain post fall: Yes . Resident stated . 'right side of face hurt' . New Interventions . Bed in lowest position, mat placed by bed, square wedge cushion placed under sheet to prevent resident from rolling out again . Additional Comments: Asked Hospice if resident could get an increase in liquid morphine . related to at times, resident lifts head and bangs it down on bed and keeps repeating until body gets closer and closer to the edge of the bed . - 8/1/23 at 11:30 PM: Health Status Note .nurse heard resident yell 'help, help, I'm on the floor!' . entered room and observed resident on the floor lying next to the bed, face was turned on the right side facing the bathroom, right arm was outstretched behind them partly under the bed, and left arm was underneath chest. This nurse called for CNA, who was down the hallway, to get the Hoyer lift (mechanical lift which uses a sling to transfer individuals). Res. was assisted back into bed by Hoyer lift and assess for injury . Res. denied pain other than to the right side of face which was laying on and was slightly red . Intervention is to have bed in lowest position, have mat next to bed, and square wedge cushion is to be placed under sheet to prevent res. from rolling out of bed . - 2/28/24 at 12:50 AM: Post-Fall Evaluation . New Intervention . A new wedge system to keep resident from rolling out of bed . - 2/28/24 at 1:17 AM: Fall . nurse heard a 'help me, help me' down short-A hall, then hurried to resident's room and observed resident lying in prone position on the mat with face/head turned towards the door. Bed in was in lowest position. This nurse asked res. what happened, and res. stated 'I fell out of bed, help me up, hurry, get me up!' Res. was turned over onto back so CAN's (Certified Nursing Assistants) could assist into bed . Review of facility provided Incident and Accident (I and A) reports for Resident #18 revealed the following: - 8/1/23 at 9:30 PM: Un-Witnessed (Fall) . nurse heard resident yell 'help, help, I'm on the floor!' Upon entering room . observed resident lying on the floor on stomach, next to bed with right arm in back of them slightly under the bed, left arm was under chest and face was turned to the right side towards the bathroom door, laying on their right cheek . resident was lifted back into bed by Hoyer and assessed for injuries . Right side of resident's face/cheek was slightly red where they were laying on it . Bed placed in lowest position. Mat placed next to bed. Square wedge cushion placed under sheet to prevent resident from rolling out of bed . No injuries observed at time of incident . Predisposing Situation Factors Restless/Agitation . Other Info: Resident kept lifting head off bed and letting it fall back on bed and kept repeating this last night . - 2/28/24 at 12:50 AM: Fall . Resident's Room . nurse heard resident yell 'help me, help me' . to resident's room to note resident lying on the floor mat next to bed in a prone position while laying on the right side of face with head turned toward the door Residents arms and hands were under abdomen. The wedge cushion used under the bed sheet to prevent resident from rolling out of bed was on the floor half under bed. The light was off. The blanket and sheet were on the floor partly wrapped up in resident's legs. Resident yell 'get me off of this floor, hurry up, get me up!' . Immediate Action Taken . Bed rotated as resident prefers to roll onto right side, preventing rolling out of bed . Predisposing Physiological Factors . Incontinent . None . Predisposing Situation Factors . Restless/Agitation . None . Pain . An interview and review of Resident #18's falls was completed with the Director of Nursing (DON) on 3/25/24 at 11:07 AM. When queried regarding the Resident's fall on 8/1/23, the DON indicated the Resident fell out of their bed. The DON then stated that as fall mat was implemented as the intervention following the fall. When queried why the wedge indicated in the post fall interventions and observed under the Resident's fitted bed sheet was not included in the active care plan, an explanation was not provided. The post fall evaluation documentation specifying Hospice was contacted to request additional pain medication (morphine) as the Resident had been lifting and banging their head down the bed and moving themselves closer to the edge of the bed the night prior to the fall and the night they fell. The DON stated, That's fair when asked where documentation was located showing indicating the Resident was having pain, what non-pharmacological interventions were attempted, and why the concern was not addressed when first identified on 7/31/23 prior to the Resident falling. When queried if additional supervision/monitoring was implemented, the DON indicated there was not. No further explanation was provided. When queried if they had additional investigation documentation pertaining to the Resident's fall on 2/28/24, the DON provided statements from two CAN's. Review of the statements revealed the Resident had last been seen by staff at 10:00/10:15 PM and was found on the floor at 12:50 AM. When queried how often staff should visually observe as well as turn and reposition dependent Residents, the DON replied every two hours. The DON was then asked why it had been over two hours since the Resident was seen by staff, per the statements, the DON did not provide an explanation. Resident #36: On 3/19/24 at 11:43 AM, Resident #36 was observed in the hallway of the facility. The Resident was propelling themselves in their wheelchair towards the exit door at the end of the hallway. There were no footrests in place on the Resident's wheelchair. Resident #36 was pleasantly confused and did not provide meaningful responses to questions when asked. At 12:00 PM on 3/19/24, Resident #36 was not present in their room. An observation of their room revealed the Resident had a raised edge mattress in place. On 3/20/24 at 11:00 AM, Resident #36 was observed sitting in their wheelchair in the activity room of the facility. The Resident's wheelchair did not have footrests in place. The Resident was pleasantly confused and did not provide meaningful responses to questions when asked. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, cerebral infarction (stroke), weakness, and repeated falls. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance to complete all ADL's with the exception of eating. The MDS further revealed the Resident had impaired Range of Motion (ROM) in one upper extremity and had one fall with no injury since the prior MDS assessment completion. Review of Resident #36's EMR revealed a care plan entitled, The resident has had an actual fall. The care plan included the interventions: - 2/2/23- fall-assist res. into a stationary chair when in the activity room; 4/18/23- post fall med review, therapy referral; 6/30/23 - Encourage to keep wheelchair at bedside and to place gripper socks on while in bed, PT eval, med review; 7/12/23 - apply gripper strips to side of bed, post-fall med review; 7/30/23 - offer to take to rest room twice during the night, encourage to keep gripper socks on while in bed; 8/11/23 - 1 assist with transfers in activity room; 9/25/23 - Commode with side rails to be placed above toilet. Neuros completed. X-ray's; 10/7/23 - Medication review, encourage call light use, toilet with evening first rounds; 10/14/23 - Toilet twice nightly and put a night light in room; 11/23/23- mat at bedside; 2/7/24: Resident to be visualized by staff when OOB (Out of Bed). Seated in common areas (Initiated: 7/30/23) - Continue interventions on the at-risk plan (2/17/23) - Encourage resident to be in commons area when awake and up to wheelchair to aid in the prevention of falls (Initiated: 10/9/23) - Mat next to bed to aid in the prevention of injury should resident attempt to self-transfer from bed (Initiated: 11/23/23) - Resident to be one of the first residents up in the morning and taken commons area (Initiated: 11/23/23) - When staff is not at nurse station take resident to activities (Initiated: 2/7/24) A second care plan entitled, (Resident #36) is at risk for falls r/t (related to) instability, shuffling gait, medication use, dementia, lack of coordination, repeated falls, impaired mobility, and poor safety awareness (Initiated: 7/12/23). The care plan included the interventions: - Ensure bed brakes are locked (Initiated: 7/7/22) - Anticipate and meet needs (Initiated: 7/7/22) - Commode to be place over resident's toilet to aid in the prevention of falls (Initiated: 9/26/23) - Encourage resident to make sure has good grip shoes on or grippy socks (Initiated: 4/18/23) - Grip strips next to bed (Initiated: 7/12/23) - Review information on falls and attempt to determine cause of falls. Record possible root causes. Alter and/or remove any potential causes if possible. Educate family/caregivers/IDT as to causes (Initiated: 4/18/23) Resident #36 had another care plan entitled, (Resident #36) had limited physical mobility r/t disease processes (Initiated: 7/7/22). The care plan included the intervention, Uses Wheelchair (ensure foot pedals are in place) (Initiated: 10/19/23). On 3/21/24, Resident #36 was observed sitting the hallway of the facility, across from the nurses' station in their wheelchair in the same place and position at 8:30 AM and 10:36 AM. The Resident's wheelchair was noted to have bilateral footrests in place at this time. Review of facility provided I and A reports revealed no additional investigation documentation and/or witness statements for any fall other than the fall on 10/14/23. Any additional documentation related to the Resident #36's falls was requested from the Director of Nursing (DON). Review of provided I and A and EMR documentation revealed Resident #36 had 11 falls from 6/30/23. Review of the falls revealed the following: - 6/30/23 at 4:15 AM: Resident #36 had an unwitnessed fall in their room/bathroom. Per the Fall note dated 6/30/23 at 4:47 AM, Staff responded to resident's bathroom call light and observed resident lying on the floor of bathroom . resident lying on right side with head under the handrail and feet out of the doorway . pain to right hip . was heading to urinate prior to falling. Encouraging resident to keep walker at bedside for use with all ambulation and will encourage use of gripper socks while in bed for safer nighttime transfers. Predisposing factors listed on the I and A form included poor lighting, transferring without assistance, and improper footwear. The intervention, Encourage to keep wheelchair at bedside and to place gripper socks on while in bed . was added to Resident #36's care plan on 6/30/23. - 7/11/23 at 3:15 PM: Resident #36 had an unwitnessed fall in their room. The Fall note dated 7/11/23 at 3:15 PM revealed, Resident was sitting on buttocks and was leaning on left arm for support in doorway facing toward the hallway . legs were extended in front of them into the hallway . walker was next to them . Regular socks on with no shoes on . Review of I and A documentation revealed predisposing factors included impaired memory and improper footwear. The intervention, Apply gripper strips to side of bed was added to the care plan on 7/12/23. - 7/30/23 at 1:36 AM: Resident #36 had an unwitnessed fall in their bathroom. Per witness statements, CAN's U heard someone calling out while checking on other residents and observed (Resident #36) sitting on the floor behind the door at approximately 1:45 AM. The Incident Note dated 7/30/23 at 1:54 AM detailed, (Resident #36) had the door open enough to see they were sitting on the floor. The note revealed staff were unable to open the door enough to enter the room and had to have the Resident slide back from the door. After entering the room, Resident #36 was observed sitting at an 85-degree angle with back toward the bed and with their legs straight out. The Resident had no pants on and was wearing regular socks. An IDT Note dated 8/2/23 at 3:38 PM detailed, IDT reviewed fall .fall likely r/t room change. prior care planned interventions were not transferred to new room. Maintenance to apply gripper strips in new room. The care plan intervention added following the fall was offer to take to rest room twice during the night, encourage to keep gripper socks on while in bed. - 8/11/23 at 10:30 AM: Resident #36 had an unwitnessed fall in the Activity Room. Per Health Status Note, the Resident was observed sitting on floor next to the table in the activity room . facing towards the hall, legs were outstretched in front of them. Rolling chair behind (Resident) . had attempted to sit on the chair, the chair rolled back, and res fell to the floor, landing on buttocks . did c/o (complain of) left hip pain while on floor, however once Hoyered (mechanical lift) up and placed in chair res denied any pain . The intervention implemented on the Post-Fall Evaluation was Resident education not to use chairs that roll. The I and A dated 8/1/23 at 11:31 AM indicated the Predisposing factors included incontinence, poor vision, weakness, ambulating without assist, and seating. Upon request for additional investigation documentation related to the fall from the DON, staff statements were provided. The statements revealed the fall was unwitnessed. Per Activity Staff T's statement, they saw Resident #36 on the floor when they sat down after gathering residents and assisting with beverages. The intervention, 1 assist with transfers in activity room was added to the care plan. - 9/25/23 at 11:40 PM: Resident #36 had an unwitnessed fall in their bathroom. The Incident Note dated 9/26/23 at 3:30 AM detailed, Nurse was called into resident's room last night at 2340 (11:40 PM). Res. observed sitting on bathroom floor with legs outstretched in front of them next to the toilet . leaning against the door frame . The floor was wet around res., who was wearing just a blouse and low-cut regular socks. Res. did not have a pull-up on . The Resident did not use any assistive devices to transfer to the bathroom. The I and A specified the Resident's left lower leg and buttocks hurt with bending and raising the leg and the immediate actions included, Mat placed next to bed and Walker moved away from bed. Predisposing factors were listed as poor lighting, wet floor incontinent, and had improper footwear. The intervention, Commode to be place over resident's toilet was added to the Resident's care plan on 9/26/23. - 10/7/23 at 11:23 AM: Resident #36 had an unwitnessed fall in their room. Per I and A form dated, 10/7/23 at 11:23 AM, Resident #36 fell in their room while trying to get up from bed to go to the bathroom and there were no witnesses. Predisposing factors listed included poor lighting, incontinence, and transferring independently. There were no nurses notes in the EMR related to the fall and no interventions were implemented. - 10/7/23 at 9:45 PM: Resident #36 had an unwitnessed fall in their room. Per documentation, facility staff were notified by another resident that Resident #3 was on the floor. Resident #36 was on the floor halfway out of their room door on their left side on the floor. Their walker was lying on the floor, and they did not have appropriate footwear in place. The Resident had left sided rib pain following the fall. An IDT note dated 10/10/23 at 3:29 PM revealed the intervention implemented following the fall was, resident to be toileted first round by CAN's (Certified Nursing Assistants) on night shift and education on call light use. - 10/14/23 at 1:30 AM: Resident #36 had an unwitnessed fall in the bathroom which resulting in a comminuted (severe break in which the bone splits into three or more pieces) displaced open fracture of the left thumb and distal phalanges (long bones in fingers) which required sutures and laceration of the right wrist which necessitated sutures. Resident #36's SBAR-Fall documentation dated 10/14/23 at 1:30 AM revealed the Resident's pain level was eight out of 10 (10 being the worst imaginable pain) at 4:08 AM on 10/14/23 (note: Resident #36 was not in the facility at 4:08 AM). The Resident's pain was in their right side of chest (ribs) . left hip . laceration site, right hand-palm - stated, 'I think I broke my back' on initial observation, but unable to pinpoint then stated pain to left side, .thumb laceration . The Resident's injuries were documented as Right hand -palm- Laceration . Left thumb deep laceration with abnormal traction of thumb. The Health Status Note dated 10/14/23 at 2:15 AM detailed, Another res. heard a thud and this resident yell for help, then called for the CAN's . nurse entered room and noted res. sitting on the floor of the bathroom with the left side of face leaning against the plastic waste basket. Res. was bleeding moderately and complaining that hands hurt. This nurse noted a bad laceration on the dorsal side of right hand, with a skin flap bent back revealing muscle. Area cleaned gently and dressed with a nonstick Telfa pad and Kerlix wrapped around hand to stop the bleeding. Resident's left thumb was bent at an angle and also cut with part of muscle hanging out. Area cleaned gently and dressed with a nonstick Telfa pad and Kerlix wrapped around hand to stop the bleeding . EMS arrived at 0200 (AM) . The I and A form dated 10/14/23 at 1:30 AM specified, Resident's left thumb was bent backward at an unusual angle and was moderately bleeding with muscle hanging out. There was blood on resident's shirt, arms, and legs, besides all over the floor. Resident was not wearing gripper socks .Immediate Action Taken: Resident cleaned up . Right hand laceration was cleaned and dressed . Left thumb was cleaned and dressed . Notes: Resident has a laceration around left thumb with muscle hanging out, which was angled backward in an unusual position . also had a recent fall this month, was educated to call for assistance when having to use the bathroom; however, resident has dementia and forgets to call for help . Predisposing factors listed included poor lighting and balance, confused, gait imbalance, and improper footwear. Review of left-hand X-ray, dated 10/14/23 at 3:32 AM from the hospital revealed, Findings . There is a comminuted fracture of the mid and distal first proximal phalanx that is angulated dorsally and radially. There is also comminuted and displaced fracture at the base of the first distal phalanx . Comminuted and displaced fractures of the left first proximal and distal phalanges. A Health Status Note dated 10/14/23 at 10:20 AM detailed, Resident returned from (hospital at) approximately 0730 AM. via EMS. Resident alert with confusion. Left hand with open displaced fx (fracture) to L thumb requiring some sutures. Resident with thumb splint in place with Kerlix. Residents L thumbnail with some bleeding noted at nail. Dressing in place. R (right) hand laceration with 4 sutures and steri strips in place. Resident looking at hands and asked, 'what happened'. Resident does not remember having fall. Resident with facial grimacing . - 10/16/23 at 12:21 PM: IDT Note . IDT members met to discuss fall. Root cause determined to be confusion and need to toilet. Immediate interventions to send to ED to eval and treat. Resident to be toileted twice nightly by staff and assist to bathroom. The Resident's care plan was updated to include the intervention, Toilet twice nightly and put a night light in room following the fall on 10/14/23. Review of facility-provided Verification of Investigation Form signed by the DON on 10/18/23 detailed, Resident said they were trying to go to the bathroom and slipped and fell . was complaining of left thumb pain and right hand. Resident typically requires 1 assist and uses a wheelchair for assistance. All care plan interventions at the time of the fall were in place and being used . History: Resident has poor situational and safety awareness due to dementia . Summary . Due to resident's inability to comprehend declines . tried to ambulate to bathroom independently. Resident did not use call light and did not turn on bathroom light. Resident fell d/t poor lighting and inappropriate safety awareness. - 10/17/23: A Fall (post) progress note dated 10/17/23 at 11:39 AM was present in Resident #26's EMR. The note specified, Res observed sitting on floor next to the table in the activity room. Res was facing towards the hall, legs were outstretched in front of them. Rolling chair behind . Res had attempted to sit on the chair, the chair rolled back, and res fell to the floor, landing on buttocks. An IDT Note dated 10/17/23 at 11:40 AM detailed, IDT met to discuss resident fall. Root cause determined to be resident independently transferring, and unsafe seating d/t wheeled chair. Interventions to be 1 assist with all transfers while in activities, and resident is not to sit on wheeled furniture . Note: An I an A form for a fall on 10/17/23 was not provided. - 11/23/23 at 10:42 AM: Per SBAR- Fall documentation in the EMR, Resident #36 had an unwitnessed fall in their room at 6:58 AM and facility staff were notified by the Resident's roommate that they were on the floor. Resident #36 was found sitting on buttocks between w/c (wheelchair) and bed facing door. Resident #36 informed staff they were attempting to go to the bathroom without assistance. The Post Fall Evaluation form for this fall detailed there was a noted pattern to falls in which falls occur in resident's room or restroom. The intervention imp[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00133950. Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #105) from 3 residents reviewed for falls. Resident #105 had a history of falls prior to admission and had two falls at the facility (on 01/07/23 and on 01/08/23) resulting in two fractures (Left distal radius fracture and left occipital fracture), hospitalization and pain. Findings Include: Resident #105: Review of the facility Face Sheet, Brief Interview for Mental Status (BIMS), dated 1/6/23), Fall Risk Evaluation dated 1/5/23, medical progress notes dated 1/5/23 through 1/9/23, revealed Resident #105 was 87 years-old, alert to self only with a BIMS of 3 (1 to 9= uninterviewable, 3=severe cognitive decline), had an evaluation score of 21 (at High Risk) for falls, with poor safety awareness; full code status and admitted on [DATE]. The resident had a history of falls with injury prior to admission to the facility. The resident's diagnosis upon admission included, recent preadmission fall with traumatic subdural hematoma (brain bleed) with neurosurgery, psychosis, metabolic encephalopathy, dementia with behavioral disturbances, and repeated falls with supervision and assistance needed for Activities of Daily Living (ADL's), transfers and ambulation. Review of facility nurse's notes dated 1/5/23, documented Resident admitted ; appears alert with confusion. Oriented to self, not aware of time, location, or circumstances. Full code at this time. Resident argumentative at times, mostly noted when (Resident #105) doesn't understand. Ambulated independently despite repeated education to seek assistance. Resident unable to remember to use call light. Review of the facility admission MDS (Minimum Data Set, resident assessment tool dated 1/13/23-Resident not in facility at this time, discharged to hospital), reported the Resident #105 was supervision and one physical assist for transfers and toileting. Review of the facility Physical Therapy notes dated 1/6/23, reported Recent head injury (just prior to admission to facility) causing new cognitive impairment and ataxia (impaired coordination caused by recent medical condition). Patient presents with balance deficits, decreased dynamic balance, decreased functional capacity, decreased safety awareness, decreased static balance, gross motor coordination deficits, postural alignment control deficits, safety awareness deficits, strength impairments and motor control deficits. Review of the facility Occupational Therapy notes dated 1/6/23, reported reduced dynamic balance and increased need for assistance from others. Review of the facility's Resident #105's cognitive care plan dated 1/5/23, reported impaired cognitive function/dementia or impaired thought r/t (related to) dementia; communicate with the resident regarding resident's capabilities. Review of the facility's Resident #105's high risk for fall's care plan dated 1/6/23, reported high risk for falls r/t dementia, poor safety awareness, hx (history) of falls; follow facility fall protocol (facility Fall Evaluation safety Guideline dated 11/28/17), anticipate and meet the resident's needs. Resident First Fall at Facility on 1/7/23: Review of the facility Incident Report dated 1/7/23, reported Resident #105 had a fall and was observed crawling on her knees on 1/7/23 at approximately 10:30 p.m. Review of Nursing Assistant/CNA L written statement dated 1/7/23, reported Around 10:30 pm, I was coming out of (another resident's room) when I saw (Resident #105) crawling in the middle of C-Hall. Review of the facility Nurse (LPN, H) statement (un-dated) reported The night resident observed walking in hallway several times (on 1/5/23) and staff assisted her back to bed without difficulty. Resident was seeking to go home; the following night (1/6/23) was my second night working with (Resident #105). I had received in report (from the hospital on 1/5/23) that her Seroquel (anti-psychotic medication, side effects: light-headiness, blurred vision, dizziness, problems moving) was discontinued from recommendation from social worker. I informed (Medical Director J) that resident remained restless and exit seeking at night and (Medical Director J) agreed to restart medication (the Seroquel). The night of the 7th (1/7/23), resident (Resident #105) was reported to this nurse by day nurse as having had increased behaviors and was given Ativan tabs ordered PRN (as needed-antianxiety medication, side effects: drowsiness/dizzy). Resident continued to have behaviors at start of shift wandering and combative with staff, so Ativan was given before resident was assisted to bed. Resident (#105) was later observed at around 10:30 p.m. crawling on hands and knees out of her room attempting to go into room across the hall. Asked resident how she came to be on the floor; I fell, I was trying to go to the bathroom. (Medical Director J) was made aware of fall and new orders to increase Depakote (seizure medication, side effects: dizziness, memory and mood changes, blurred vision). Residents Second Fall at Facility on 1/8/23: Review of the facility Incident Report dated 1/9/23, documented Patient (Resident #105) tried to stand from wheelchair while in her room near sink area. Unsuccessful transfer, patient complained of pain to wrist and right shoulder. Patient sent to ER for evaluation. Hospital completed series of x rays and reported on 1/9/23 at 3:30p of a hip and wrist fracture. The Incident report was completed on 1/9/23 (day after resident fell). Review of nurses (LPN, H) notes (un-dated) reported on 1/8/23, (Resident #105) sat in w/c (wheelchair) and both this nurse and CNA (Nursing Assistant/ F) assisted her with toileting. Then this nurse reported behavior to (Medical Director J), overheard resident yelling no repeatedly to CNA asking to help her into bed. CNA (CNA F) left resident (#105) in w/c at her request and came just outside room to tell this nurse (Nurse H) she refused to go to bed then we both heard resident yell out as she fell. Observed resident sitting on floor in front of sink stating that her wrist hurt, wanting ice. Ice pack provided and placed to resident satisfaction (Medical Director J) made aware of fall and ordered Ativan IM (intermuscular) to be given. EMS (Emergency Medical Service) called at that time from residents' bedside and was transferred to ER (Emergency Room) for being un-responsive. Review of the facility physician order dated 1/9/23 at 02:07 (2:07 a.m.), reported Ativan Injection Solution 2 MG/ML inject 0.1 ml intramuscularly STAT for agitation dose not administered. Resident unresponsive; transferred to ER. Review of hospital records dated 1/10/23, reported Left distal radius fracture, left occipital fracture, potential for right hip fracture. Due to frequent falls and other comorbidities, the family has elected to start hospice care. Review of facility fall investigation report for 1/8/23 (un-dated) reported CNA (F) went to the nurse's station to report refusal of care to the nurse (Nurse H) 10 ft away approx. and get her assistance. Less than 30 seconds later res. (resident #105) could be heard yelling. Resident was observed by (Nurse H) sitting on the floor in front of sink. Currently resident at the hospital because she is 1:1 (one-on-one for supervision). Review of the facility CNA F's written statement dated 1/8/23, documented I helped resident (Resident #105) off the toilet into her wheelchair. I asked the resident if she wanted to lay down, she began to yell at me saying no, no, no. I went down the hall to tell the nurse she did not want to lay down. Just as I told the nurse we heard a noise coming from down the hall we walked into her room, and I observed the resident laying on her back on the floor. During a phone interview done on 2/2/23 at 8:43 a.m., CNA F stated When I got on shift, I got report (Resident #105) was restless and combative and confused. She was standing up in the hallway with the nurse, I got her in her wheelchair. I wheeled her to her bed, she started yelling, she didn't want to lay down. I told her you can sit in your wheelchair. I told her let us know when she wanted to go to bed (Resident #105 had a BIMS of 3 and was combative at this time). I assumed she would come out in the hallway. I walked out of the room, talked to (Nurse H) and told her she would not lay down and we heard a bump. Her wheelchair had rolled out from behind her, it rolled back. I did not lock her wheelchair because it's a restraint. She was sitting on her bottom leaning against the sink. I left her alone in the room to notify the nurse. When this surveyor asked CNA F if she could have used the call light or hollered for assistance she stated, I probably should have hollered out for somebody. During an interview done on 2/3/23 at 10:38 a.m., Nurse H revealed CNA F did leave the residents room and leave her alone to come to inform her she would not go to bed. Nurse H said CNA F should not have left the resident alone in her room when she was trying to get up. Resident #105 had fallen the day prior to her 1/8/23 fall and had an extensive history of falls and behaviors with decreased cognition assessed and confirmed by facility staff. During an interview done on 2/2/23 at approximately 9:00 a.m., the Administrator stated (Resident #105) could un-lock it (her wheelchair); she was folding clothes the first night she was here, she was able to un-lock her wheelchair. During an interview done on 2/2/23 at 9:30 a.m., Director of Rehab Services PTA K was asked by this surveyor if a locked wheelchair was a restraint and she stated, locking a wheelchair is not a restraint, more safety. Review of the facility Restraint Use policy dated 4/21/20, reported Physical Restraint: any manual method, physical or mechanical device, equipment, or material that meets all of the following: Is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts freedom of movement or normal access to his/her body. Review of the facility Fall Evaluation Safety Guideline policy dated 11/28/17, reported Identification of resident risk for accidents on admission: Utilize medical history and physical exam, observe resident in environment, individualized assessment for safety need for supervision. Falls Relates to Confusion: Place confused and/or risk residents close to the nursing station for observation and/or provide with diversional and targeted individualized activity. Multiple Falls: Keep resident in view during high risk times, if possible (this includes bring residents up to the nurse's station for close observation), Review the direct caregivers and ask them for intervention ideas. Refer to Therapeutic Recreation for activity intervention during high-risk movement groups, hydration, group activity, etc. (this includes documenting interventions prior to medication use).